Where are the limits of medicine: are we turning the whole world into patients? Richard Smith Editor BMJ

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?

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

“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

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)

Time for a total body scan? The perfect Valentine’s 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

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, and]over 53 would have abnormal biopsy results During this time one woman would die of cervical cancer despite being screened

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?

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%

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 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 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