to much medical?

[Guest guest]

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's power to harm

individual patients and whole populations, presumably few would agree

with Ivan Illich that " The medical establishment has 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 counterproductive and produce more harm than

good. So where is that point, and might we have reached it already?

 

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 deserve far more intense

debate in a world where many countries are steadily increasing their

investment in health care. Presumably no one wants to keep cutting

back on education, the arts, scientific research, good food, travel,

and much else as we spend more and more of our resources on an

unwinnable battle against death, pain, and sicknessparticularly if

Illich is right that in doing so we destroy our humanity. And do we

in the rich world want to keep developing increasingly expensive

treatments that achieve marginal benefits when most in the developing

world do not have the undoubted benefits that come with simple

measures like sanitation, clean water, and immunisation?

 

Any consideration of the limits of medicine has to begin a quarter of

a century ago with Illich, who has so far produced the most radical

critique of modernor industrialisedmedicine.1 His argument is in some

ways simple. Death, pain, and sickness are part of being human. All

cultures have developed means to help people cope with all three.

Indeed, health can even be defined as being successful in coping with

these realities. Modern medicine has 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 than to learn, to heal, and to find their

own way. " The analysis is supported by Amartya Sen's data showing

that the more a society spends on health care the more likely are its

inhabitants to regard themselves 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 course much easier

to offer a critique of cultures than to create new onesand Illich

(like doctors, ironically) is much stronger on diagnosis than cure.

But he does write about recovering the ability for mutual self care

and then learning to combine this with the use of modern technology.

Though his polemic was published long before the internet, this most

contemporary of technologiescombined with the move to patient

partnershipis shifting power from doctors back to people. People may

increasingly take charge, more consciously weighing the costs and

benefits of the " medicalisation " of their lives. Armed with better

information about the natural course of common conditions, they may

more judiciously assess the real value of medicine's never ending

regimen of tests and treatments.

 

Although some forcesthe internet and patients' empowermentmight offer

opportunities for " de-medicalisation, " many others encourage greater

medicalisation. Patients and their professional advocacy groups can

gain moral and financial benefit from having their condition defined

as a disease.3 Doctors, particularly some 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 almost all of us as sick, by diagnosing

the " deficient " genes that predispose us to disease.4 Global

pharmaceutical companies have a clear interest in medicalising life's

problems, 5 6 and there is now an ill for every pill.7 Likewise

companies manufacturing mammography equipment or tests for prostate

specific antigen can grow rich on the medicalisation of risk.8 Many

journalists and editors still delight in mindless medical formulas,

where fear mongering about the latest killer disease is accompanied

by news of the latest wonder drug.9 Governments may even welcome some

of society's problemswithin, for example, criminal justicebeing

redefined as medical, with the possibility of new solutions.

 

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 many of life's

normal processesbirth,12 ageing,13 sexuality,14 unhappiness,15 and

death16can be medicalised. Two sets of authors in the issue argue

convincingly, however, that there is much undertreatment, suggesting

a need for more medicalisation. 13 17 The challenge is to get the

balance right.

 

It is those who pay for health care who might be expected to resist

medicalisation, and governments, insurers, and employers have tried

to restrain the rapid and unceasing growth in healthcare budgets.

They have had little or no success, and Britain's government now

plans to raise taxes to pay for more health care. Labour, the party

in power, will have calculated that the risk of trying to bottle up

demand is greater than thesubstantialrisk of raising taxes. 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 problem worse, eroding still

further the human capacity to cope with reality.

 

Ivan Illich did not want the wholesale dismantling of medicine. He

favoured " sanitation, inoculation, and vector control, well-

distributed health education, healthy architecture, and safe

machinery, general competence in first aid, equally distributed

access to dental and primary medical care, as well as judiciously

selected 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, particularly if

available to everybody everywhere.

 

Doctors and their organisations understandably argue for increased

spendingbecause they are otherwise left paying a personal price,

trying to cope with increasing demand with inadequate resources.

Indeed this is one of the sources of worldwide unhappiness among

doctors.18-20 Although seen by many as the perpetrators of

medicalisation, doctors may actually be some of its most prominent

victims.3 This is perhaps why BMJ readers wanted this theme issue.

 

Perhaps some doctors will now become the pioneers of de-

medicalisation. They can hand back power to patients, encourage self

care and autonomy, call for better worldwide distribution of simple

effective health care, resist the categorisation of life's problem as

medical, promote the de-professionalisation of primary care, and help

decide which complex services should be available. This is no longer

a radical agenda.

 

Ray Moynihan, journalist.

 

Australian Financial Review, Sydney 2201, Australia

(ray_128)

 

Richard Smith, editor.

 

BMJ(rsmith)