Transcript Too much medicine?

Too much medicine?
Richard Smith
Editor BMJ
www.bmj.com/talks
What I want to talk
about
• What is medicalisation?
• Medicalisation of birth, death, and
sexuality
• 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?
What is medicalisation?
• Medicalisation is the process of
defining an increasing number
of life’s problems as medical
problems
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
Rise in caesarean sections
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
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 it’s still common practice in much of
the world--for example, Spain and Taiwan
Why demedicalisation?
• The women’s movement
• Organisations like the Natural
Childbirth Trust
• Evidence based medicine
(evaluating the effectiveness of
interventions)
• “Radical midwives”
Medicalisation of death
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
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
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
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 don’t manage
one mutual orgasm a night?
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 it’s 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)
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
• Controversy surrounds current attempts to medicalise
sexual problems and establish "normative data" for a
range of physiological measurements of female sexual
response
Who is healthy?
• “Somebody who hasn’t had
enough diagnostic tests?”
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)
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 "nondiseases"and found almost 200
• To have your condition labelled as a disease may bring
considerable benefit--both material (financial) and
emotional
• However, the diagnosis of a disease may also create
problems you may be denied insurance, a mortgage, and
employment
• A diagnosis may also lead you to regard yourself as
forever flawed and unable to "rise above" your problem
“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
• Osteoporosis: “thin bones” are a risk factor for
fractures, but at what point does osteoporosis become
a disease?
• Menopause: is this natural ageing or something to be
treated? Is it the mass drugging of women for the
gratification of men? Treatment is harmful
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
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 country’s
wealth is spent on health care
• Doctors are oppressed by being under
pressure to “solve” problems they cannot
solve
Forces promoting
medicalisation
• “Patients”
• The decay of cultural,
particularly religious, ways of
managing difficulties
• Pharmaceutical companies
• Doctors, particularly specialists
Forces promoting
medicalisation
• “In Scotland, where I was born,
death was seen as imminent. In
Canada, where I trained, it was
thought inevitable. In California,
where I now live, it’s seen as
optional.”
• Ian Morrison, former preseident of the
Institute for the Future
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. They want
their doctor to act as lawyer and priest. As a lawyer, the doctor
exempts the patient from his normal duties and enables him to
cash in on the insurance fund he was forced to build. As a priest,
he becomes the patient's accomplice in creating the myth that
he is an innocent victim of biological mechanisms rather than
lazy, greedy, or envious deserter of a social struggle over the
tools of production. Social life becomes a giving and receiving of
therapy: medical, psychiatric, pedagogic, or geriatric. Claiming
access to treatment becomes a political duty, and medical
certification a powerful device for social control.” Ivan Illich
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
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
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
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