Where are the limits of medicine: are we turning the whole world into patients

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Where are the limits of medicine are we turning
the whole world into patients?

• Richard Smith
• Editor BMJ
• www.bmj.com/talks

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What I want to talk about

• What is medicalisation?
• Medicalisation of birth, death, and sexuality
• Screening a major medicalisaing force?
• What is normal? What is a disease?
• Creating diseases disease mongering
• Why does medicalisation matter?
• What are the forces driving medicalisation?
• How should we respond?

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What is medicalisation?

• Medicalisation is the process of defining an
  increasing number of lifes problems as medical
  problems

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Medicalisation of birth

• Caesarean section rates are rising consistently
  around the world
• 90 of babies are delivered by caesarean section
  in some parts of Brazil
• It has at some times and in some places been
  normal to give women giving birth a general
  anaesthetic
• In Britain in the 30s upper class women were more
  likely to die in childbirth than poorer
  women--because of excessive intervention

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Rise in caesarean sections
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Why have Caesarean section rates risen?

• Losing the skills needed for less dramatic
  interventions
• Medicolegal pressures
• More involvement of doctors, less of midwives
• Private practice
• Not involving women in decision making

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Medicalisation and demedicalisation of birth

• When my first son was born in 1982 my wife had an
  enema, her pubic hair shaved, and the baby
  monitored (and would have had an episiotomy if
  she had not had an emergency Caesarean section)
• When my daughter was born in 1991 all this had
  gone
• There was no evidence that any of it works
• Yet its still common practice in much of the
  world--for example, Spain and Taiwan

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Why demedicalisation?

• The womens movement
• Organisations like the Natural Childbirth Trust
• Evidence based medicine (evaluating the
  effectiveness of interventions)
• Radical midwives

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Medicalisation of death
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Medicalisation of death

• In Scotland, where I was born, death was viewed
  as imminent. In Canada, where I trained, death
  was seen as inevitable. In California, where I
  live now, death is thought to be optional.
• Ian Morrison, former president of the Institute
  for the Future

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Ivan Illich's critique of the medicalisation of
dying

• A loss of the capacity to accept death and
  suffering as meaningful aspects of life
• A sense of being in a state of "total war"
  against death at all stages of the life cycle
• A crippling of personal and family care, and a
  devaluing of traditional rituals surrounding
  dying and death
• A form of social control in which a rejection of
  "patienthood" by dying or bereaved people is
  labelled as a form of deviance

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Medicalisation of death

• People want to die at home but mostly they die in
  hospital
• Increasingly everybody must have their chance in
  intensive care before being allowed to die
• Palliative care started as a response to
  medicalisation of death but may now be part of
  the medicalisation process

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Elements of a "good death" in modern Western
culture

• Pain-free death
• Open acknowledgement of the imminence of death
• Death at home, surrounded by family and friends
• An "aware" death in which personal conflicts and
  unfinished business are resolved
• Death as personal growth
• Death according to personal preference and in a
  manner that resonates with the person's
  individuality

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Medicalisation of sexuality

• A rich area for medicalisation because how do we
  know what is normal?
• 19th century medicine saw too much sexual
  activity (particularly masturbation) as a
  disease
• 21st century medicine is more likely to see too
  little sexual activity as a disease
• Are you abnormal if you dont manage one mutual
  orgasm a night?

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Male sexuality

• Many men have sexual difficulties, but when are
  these best managed by doctors?
• Advertisements paid for by the manufacturers of
  Viagra suggest that 40 of men have problems with
  erections
• But its actually 3 of 40 year olds and 60 of
  70 year olds
• he British rationing of Viagra suggests that
  there is good impotence (mostly physical) and
  bad impotence (mostly psychological)

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Female sexual dysfunction a disease in the
making

• Researchers with close ties to drug companies are
  defining and classifying a new medical disorder
  at company sponsored meetings
• The corporate sponsored definitions of "female
  sexual dysfunction" are being criticised as
  misleading and potentially dangerous
• Commonly cited prevalence estimates, which
  indicate that 43 of women have "female sexual
  dysfunction," are described as exaggerated and
  are being questioned by leading researchers

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Who is healthy?

• Somebody who hasnt had enough diagnostic tests?

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Who is normal?

• Within two standard deviations of the mean (5
  abnormal on every test)
• A level that carries no extra risk (we all have
  high cholesterol compared with Pacific islanders)
• Beyond a point at which treatment does more good
  than harm (depends on effectiveness of treatment)
• Politically or culturally aspired to
  (homosexuality)

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Time for a total body scan?

• The perfect Valentines day gift
• Buy one get one free
• There are likely to be hundreds of false
  positives
• You will need umpteen further diagnostic tests,
  each with the probability of producing further
  false positives

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Too much cervical screening?

• 1000 women have to be screened for 35 years to
  prevent one death
• One nurse performing 200 tests a year would
  prevent one death in 38 years
• During this time she or he would care for over
  152 women with abnormal results
• 79 women would be referred for investigation,
  andover 53 would have abnormal biopsy results
• During this time one woman would die of cervical
  cancer despite being screened

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And...

• Screening for cancer of the prostate, ovaries,
  colon, and breast, lung, and so on
• To be followed by screening for abnormal genes
• What is your chance of being normal?

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Is the BMJ promoting medicalisation?

• Everybody on their 50th birthdays should start
  taking the polypill
• It comprises aspirin, a statin, folic acid, and
  three antihypertensives at half dose
• No need for any tests
• Deaths from heart disease and stroke will be
  reduced by 80

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What is a disease?

• We might think of a disease as like a
  species--something that exists in nature and is
  waiting to be discovered
• In fact disease is a medical and social
  construct--and as such a very slippery concept
• The BMJ conducted a survey on the web to identify
  "non-diseases"and found almost 200
• To have your condition labelled as a disease may
  bring considerable benefit--both material
  (financial) and emotional

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Disease mongering

• Baldness losing hair may lead to panic and poor
  mental health Baldness See your doctor on the
  back of buses
• Irritable bowel syndrome functional bowel
  problems are very common now there is a drug the
  disease is being marketed
• Social phobia one million Australians may have
  this problem--now there is a drug

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Why might medicalisation be a problem?

• People are treated when they are normal
• Non-medical, perhaps traditional, ways of
  managing difficulties are devalued and even
  destroyed
• We see ourselves as victims and perhaps fail to
  take action ourselves

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Why might medicalisation be a problem?

• All effective treatments have side effects
• Political and social problems demand political
  and social solutions but may be treated medically
• An increasing proportion of a countrys wealth is
  spent on health care
• Doctors are oppressed by being under pressure to
  solve problems they cannot solve

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Forces promoting medicalisation

• Patients
• The decay of cultural, particularly religious,
  ways of managing difficulties
• Pharmaceutical companies
• Doctors, particularly specialists

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Forces promoting medicalisation

• "In a morbid society the belief prevails that
  defined and diagnosed ill-health is infinitely
  preferable to any other form of negative label or
  to no label at all. It is better than criminal or
  political deviance, better than laziness, better
  than self-chosen absence from work. More and more
  people subconsciously know that they are sick and
  tired of their jobs and of their leisure
  passivities, but they want to hear the lie that
  physical illness relieves them of social and
  political responsibilities.

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Forces promoting medicalisation

• ".....an expanding medical establishment, faced
  with a healthier population of its own creation,
  is driven to medicating normal life events (such
  as the menopause), to converting risks into
  diseases, and to treating trivial complaints with
  fancy procedures. Doctors and 'consumers' alike
  are becoming locked within a fantasy that unites
  the creation of anxiety with gung-ho 'can-do,
  must- do' technological perfectibilism everyone
  has something wrong with them, everyone can be
  cured."
• Roy Porter

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How to respond to medicalisation

• Encourage debate and understanding of
  medicalisation
• Help people understand that diseases are
  medically and socially created
• Help people understand the severe limitations and
  risks of medicine
• Move away from using corporate funded information
  on medical conditions/ diseases

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How to respond to medicalisation

• Generate independent accessible materials on
  conditions and diseases Promote non-medical ways
  of responding to problems
• Spread knowledge--for example, through the
  internet
• Encourage self care

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How to respond to medicalisation

• Create more organisations like the Natural
  childbirth trust
• Resist direct to consume advertising
• Resist the constant growth in health budgets