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"Too much medicine? Almost certainly"

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http://bmj.com/cgi/content/full/324/7342/859


BMJ 2002;324:859-860 ( 13 April )

Editorials

Too much medicine?

Almost certainly

Most doctors believe medicine to be a force for good. Why else would they have become doctors? Yet while all know medicine'spower to harm individual patients and whole populations, presumablyfew would agree with Ivan Illich that "The medical establishmenthas become a major threat to health."1 Many might, however, accept the concept of the health economist Alain Enthoven that increasing medical inputs will at some point become counterproductiveand produce more harm than good. So where is that point, and mightwe have reached italready?

Readers of the BMJ voted in a poll for us to explore these questions in a theme issue of the BMJ, and this is that issue.Unsurprisingly, we reach no clear answers, but the questions deservefar more intense debate in a world where many countries are steadilyincreasing their investment in health care. Presumably no onewants to keep cutting back on education, the arts, scientificresearch, good food, travel, and much else as we spend more andmore of our resources on an unwinnable battle against death, pain,and sickness---particularly if Illich is right that in doing sowe destroy our humanity. And do we in the rich world want to keepdeveloping increasingly expensive treatments that achieve marginalbenefits when most in the developing world do not have the undoubtedbenefits that come with simple measures like sanitation, cleanwater, andimmunisation?

Any consideration of the limits of medicine has to begin a quarter of a century ago with Illich, who has so far produced themost radical critique of modern---or industrialised---medicine.1His argument is in some ways simple. Death, pain, and sicknessare part of being human. All cultures have developed means tohelp people cope with all three. Indeed, health can even be definedas being successful in coping with these realities. Modern medicinehas unfortunately destroyed these cultural and individual capacities, launching instead an inhuman attempt to defeat death, pain, and sickness. It has sapped the will of the people to suffer reality. "People are conditioned to get things rather than to do them . . . They want to be taught, moved, treated, or guided rather thanto learn, to heal, and to find their own way." The analysis issupported by Amartya Sen's data showing that the more a societyspends on health care the more likely are its inhabitants to regardthemselves as sick.2

Illich's critique may seem laughable, even offensive, to the doctor standing at the end of the bed of a seriously ill person.Should the patient be thrown out and told to cope? It is of coursemuch easier to offer a critique of cultures than to create newones---and Illich (like doctors, ironically) is much stronger ondiagnosis than cure. But he does write about recovering the abilityfor mutual self care and then learning to combine this with theuse of modern technology. Though his polemic was published longbefore the internet, this most contemporary of technologies---combinedwith the move to patient partnership---is shifting power from doctorsback to people. People may increasingly take charge, more consciouslyweighing the costs and benefits of the "medicalisation" of theirlives. Armed with better information about the natural courseof common conditions, they may more judiciously assess the realvalue of medicine's never ending regimen of tests andtreatments.

Although some forces---the internet and patients' empowerment---might offer opportunities for "de-medicalisation," many othersencourage greater medicalisation. Patients and their professionaladvocacy groups can gain moral and financial benefit from havingtheir condition defined as a disease.3 Doctors, particularlysome specialists, may welcome the boost to status, influence,and income that comes when new territory is defined as medical.Advances in genetics open up the possibility of defining almostall of us as sick, by diagnosing the "deficient" genes that predisposeus to disease.4 Global pharmaceutical companies have a clearinterest in medicalising life's problems, 5 6 and there isnow an ill for every pill.7 Likewise companies manufacturingmammography equipment or tests for prostate specific antigen cangrow rich on the medicalisation of risk.8 Many journalistsand editors still delight in mindless medical formulas, wherefear mongering about the latest killer disease is accompaniedby news of the latest wonder drug.9 Governments may even welcomesome of society's problems---within, for example, criminal justice---beingredefined as medical, with the possibility of newsolutions.

As the BMJ 's debate over "non-diseases" has shown, the concept of what is and what is not a disease is extremely slippery. 10 11 It is easy to create new diseases and new treatments, and manyof life's normal processes---birth,12 ageing,13 sexuality,14unhappiness,15 and death16---can be medicalised. Two sets ofauthors in the issue argue convincingly, however, that there ismuch undertreatment, suggesting a need for more medicalisation. 13 17 The challenge is to get the balanceright.

It is those who pay for health care who might be expected to resist medicalisation, and governments, insurers, and employershave tried to restrain the rapid and unceasing growth in healthcarebudgets. They have had little or no success, and Britain's governmentnow plans to raise taxes to pay for more health care. Labour,the party in power, will have calculated that the risk of tryingto bottle up demand is greater than the---substantial---risk of raisingtaxes. But while increased resources will be widely welcomed,the cost of trying to defeat death, pain, and sickness is unlimited,and beyond a certain point every penny spent may make the problemworse, eroding still further the human capacity to cope withreality.

Ivan Illich did not want the wholesale dismantling of medicine. He favoured "sanitation, inoculation, and vector control,well-distributed health education, healthy architecture, and safemachinery, general competence in first aid, equally distributedaccess to dental and primary medical care, as well as judiciouslyselected complex services."1 These should be embedded within"a truly modern culture that fostered self-care and autonomy."This is a package that many doctors would find acceptable, particularlyif available to everybodyeverywhere.

Doctors and their organisations understandably argue for increased spending---because they are otherwise left paying a personalprice, trying to cope with increasing demand with inadequate resources.Indeed this is one of the sources of worldwide unhappiness amongdoctors.18-20 Although seen by many as the perpetrators of medicalisation,doctors may actually be some of its most prominent victims.3This is perhaps why BMJ readers wanted this themeissue.

Perhaps some doctors will now become the pioneers of de-medicalisation. They can hand back power to patients, encourage selfcare and autonomy, call for better worldwide distribution of simpleeffective health care, resist the categorisation of life's problemas medical, promote the de-professionalisation of primary care,and help decide which complex services should be available. Thisis no longer a radicalagenda.

Ray Moynihan, journalist

Australian Financial Review, Sydney 2201, Australia(ray_128@hotmail.com)

Richard Smith, editor

BMJ(rsmith@bmj.com)
This article has been cited by other articles:

  • Moynihan, R., Smith, R. (2002). Too much medicine?. BMJ 324: 859-860 [Full text]  

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Date: 10-11-2002