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Evolving sociological analyses of ‘pharmaceuticalisation’: a response to Williams, Martin and Gabe

2011; Wiley; Volume: 33; Issue: 5 Linguagem: Inglês

10.1111/j.1467-9566.2011.01353.x

1467-9566

John Abraham,

Pharmaceutical Economics and Policy

Gabe (1984, 1990) developed sociology of tranquilliser prescribing. Although never using the phrase, 'tranquillisation of society', his research engaged that issue, arguably a subset of 'pharmaceuticalisation'. He explained declining tranquilliser prescriptions, by reference to doctors, patients, the state, the pharmaceutical industry, and mental health organisations (Gabe 1990). The analysis was way ahead of its time (cf. Busfield 2010), but also a product of its time. It did not consider pharmaceutical industry promotion, such as detailing and disease-awareness campaigns, which nowadays preoccupy the field (Fishman 2004, Greene 2004, HCHC 2005). Gabe importantly noted Government influence via 'limited lists' for NHS prescribing, but his definition of 'the state' omitted regulatory authorities, which subsequently became central to pharmaceutical sociology (Abraham 2009, Abraham and Lewis 2000, Abraham and Sheppard 1999). While Gabe pioneered 'tranquilliser studies' within medical sociology, from the late 1980s, I developed perspectives from political sociology and 'realist' sociology of science/technology to research pharmaceutical development, testing, and regulation – the bases for knowledge-claims within medical practices, yet ignored by medical sociology (Abraham 1995, 2008). However, by the late 1990s, cross-fertilisation/hybridisation between our two traditions had evolved (Elston 1997). Today, sociological discussion of growth/decline in prescribing without reference to drug development/regulation/promotion issues seems inconceivable, just as political analyses of the pharmaceutical industry/regulatory state increasingly includes medical professionals/patient-groups (Davis and Abraham 2011a). In this context, discussions of pharmaceuticalisation of society have emerged, of which Williams et al. (2011) is the latest version. Thus, there has been sustained sociological analysis of pharmaceuticals over the last 20 years pertinent to 'pharmaceuticalisation', but the concept has been introduced only recently for various conceptual/empirical reasons explained elsewhere (Abraham 2010). Williams et al.'s (2011) contribution is important and commendable for building on established works. I endorse many of their points and analytical frameworks, but have some problems and constructive criticisms. I defined 'pharmaceuticalisation' as: 'the process by which social, behavioural, or bodily conditions are treated, or deemed to be in need of treatment, with medical drugs by doctors or patients' (Abraham 2010: 604). Williams et al. (2011: 711) define it as: 'translation or transformation of human conditions, capabilities and capacities into opportunities for pharmaceutical intervention'. Unlike my definition, theirs could include taking heroine/cocaine or overdosing on drugs to commit suicide – all 'opportunities for pharmaceutical intervention'. I wondered if such an expansive definition is envisaged by these authors. Relatedly, does 'enhancement' include taking illicit drugs to 'enhance' one's immediate state of mind? Is 'enhancement' defined entirely by the user or does it have some objective status? Methodologically, there is no necessary fit between upstream-macro and downstream-micro (Williams et al. 2011: 711). One can conduct a micro-sociological analysis of a regulatory decision. I disagree that Busfield (2010)'convincingly shows' that the 'progressive' account of pharmaceutical expansion 'is of limited explanatory value' (Williams et al. 2011: 712). She merely asserts that the account 'presents an idealised, over-simple picture' (Busfield 2010: 935). This is a weakness (unchallenged by Williams et al.), especially in connection with practitioners expecting the material reality of 'therapeutic diffusion' to be fully confronted (Abraham 2010). I recoiled from regarding Japan as 'Western'. Given growing Japanese, Brazilian and Indian pharmaceutical exports, should the Westernisation thesis be so readily accepted? Williams and colleagues are right to reiterate redefinition of health problems and changing forms of governance as drivers of pharmaceuticalisation. The latter phenomenon can be concisely characterised by the increasing role of what Abraham and Davis (2009) call the 'permissive principle' in drug evaluation/regulation. Regarding innovation, sociological analysis is now challenging how it is defined/counted (Davis and Abraham 2011b). Williams and colleagues' ideas about pharmaceutical futures are interesting, but the discussion left me asking: whose expectations? What sociological framework enables us to disaggregate expectations – regulators' expectations may be of 'proof', rather than 'hope' (Abraham and Davis 2007). That the media can promote or challenge pharmaceutical use is well established (Bury and Gabe 1994, Gabe and Bury 1996). How Williams et al. go beyond that is undeveloped. The hypothesis that media coverage of pharmaceuticals begins supportively and gradually becomes critical over a drug's life-cycle is interesting, but given the examples cited, it is unclear whether that is a function of the type of pharmaceuticals under study or the nature of the media. Consequently, measurement of independent media effects would seem difficult within the conceptualisation presented. Pharmaceutical industry marketing, consumerism, and the ideology of the 'expert patient' are important factors in 'pharmaceuticalisation', which Williams and colleagues rightly emphasise. However, the potential for comparing cases of declining pharmaceuticalisation and/or what I have called 'de-pharmaceuticalisation' with areas of growth as a means to understand the dynamics of the sector is surprisingly underplayed, given Gabe's roots in explaining tranquilliser decline (Abraham 2010: 611).