IHAVE received a great deal of feedback about the original article upon which this publication is based. I feared repercussions. Instead many practicing nurses, a few physicians, students in nursing, and the lay public wrote to say that a recounting of my experience gave voice to something they had been feeling or thinking for a very long time. So it is gratifying to see that 3 nurses have written an article in an effort to extend and explicate the ideas I set forth 3 years ago. Each author contributed to their joint purpose defined as "[horizontal ellipsis]to evolve (nursing) further as a field worthy of human inspiration." As a reader, I feel privileged to be on an inside track with personal narrations that are conceived within such a sensitive context.

My essay was meant to be personal, based on of a case of one, including my observations of events that occurred while I was going through my cancer diagnosis, treatment, and follow-up. As such I eschewed theoretical language, provided no definitions, and included none of the rich background of literature from nursing, cultural anthropology, and sociology.

I believe that my article and this one would have been somewhat enriched had we all stepped back to anchor ourselves within the embedded social and cultural meaning of medicalization. I will try briefly to remedy this deficiency since 1 or more of these authors discussed medicalization in a way that left the impression that they were talking about helpful or not helpful medical care. On the contrary, medicalization is a form of organized and systemic oppression that is so culturally entrenched, powerful, and invisible, that everyone's choices, including those practicing in the biomedical field are manipulated, and options are precluded with scant awareness on the part of any of the actors.

When one has a serious disease, the playing field is not level for the consumer because the consumer is not privy to the unfolding and enactment of the paradigm and the science from which treatments spring. Moreover, the history of organized medicine has been one of using power and legal tactics to abolish all competing professions in order to secure a monopoly and to protect exclusive rights to medical treatment. These efforts continue in oncology and other specialties as we speak. Even medical doctors themselves are kept in line. Many physicians who provide alternative treatments for cancer, especially if they are successful and well-known, are threatened with prosecution and revocation of license.

Medicalization of cancer limits severely what is taught, studied, and practiced. Advances in the field are presented without external critical assessment and touted, even when there is very little scientific evidence to back up claims. Similarly, McPherson found in her trenchant analysis of medicalization in osteoporoses and menopause that

Evidence abounds [horizontal ellipsis] that the claim of therapeutic gain has sometimes been used to justify medical intervention even when the "scientific evidence" was unconfirmed or contradictory.1^(p15)

Upon close inspection, it becomes clear that medical practice is based as much on myths, opinions, and tradition as on objective data.2 Industry power allows complete control of emerging evidence by determining how clinical trials are set up, conducted, and reported. Treatments may be offered and even advertised that have very little actual effect if any.3,4 Guiding the paradigm are battle metaphors buttressed by instilling hope for a cure or remission in frightened patients who may express qualms about questionable interventions that are life-threatening and debilitating, and offer little in the way of documented outcomes.

One bit of evidence that oncologists use to document that oncology is "wining the war" is gains in 5-year survival, much of which can actually be attributed to lead time bias.4 In other words, more people are living longer with cancer not because of the treatment, but because they are diagnosed early in the disease instead of when they are close to succumbing from it, so they may live many years longer with the diagnosis than they would have before secondary prevention efforts were common.

In the article under critique, a sentence like "[horizontal ellipsis] how can we create a life-enhancing co-existence for those of us who choose to blend approaches from both medicalization (my italics) and alternative understandings of the human condition" is confusing. This not only confounds paradigm and practice, it ignores the fact that some alternative fields may be quite medicalizing as well. Everybody can play this power game. The battles in some states between alternative providers attempting to constrain legally each other's scope of practice and co-opt patients make the conflicts between the AMA and advanced practice nursing look like a backyard croquet match.

So medicalization is a form of cultural oppression that is carried out with social sanction and economic, political, and legal backing. Therefore, it is very hard to understand how medicalization could have positive consequences, as the authors concluded. I agree that some forms of medical practice have very positive consequences, and mainly these are in the categories of diagnostic conditions to which the narrow biomedical metaphor of "germ theory" can be applied most directly. But saying medicalization is positive would be likened to proclaiming that sexism has positive consequences because some women find fulfillment in lower paying jobs.

Medicalization limits healthcare not only because it restricts options internal and external to the field, but also because the collective power is invoked so much further up the line than where treatment decisions finally drift down to impinge on the interaction between the provider and the patient. Consistent with Marxian theory, the result is a reification of the oppressors' point of view5 and a form of alienation for those who suffer under the subjugation whether they are conscious of being oppressed or not.

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