BMJ 2002;324 ( 13 April )

Editor's choice

Postmodern medicine

Uwe Reinhardt, perhaps America's funniest economist, spoke some years ago of what might happen as spending on health care ate up ever larger chunks of gross domestic product. Coast to coast America would become one enormous hospital, with everyone either working in health care or being ill (or both). Reinhardt might therefore appreciate this issue on medicalisation which discusses much the same problem but from a doctor's eye view, rather than an economist's.

Not that economists don't get a look in. Amartya Sen, an even more distinguished economist, discusses the paradox that people in America feel much less well than those in Bihar, India, though their life expectancy is much better (p 860). Indeed, a direct relation seems to exist between self reported morbidity and life expectancy. He uses this example to caution against assuming that patients' perceptions should always trump those of experts.

But the shadow that really hangs over this issue is that of Ivan Illichauthor of Medical Nemesis and Limits to Medicine (reviewed, along with other old classics, on p 923). His argument, explained in the opening editorial (p 859), is that modern medicine has become a threat to health by undermining the capacity of individuals and societies to cope with death, pain, and sickness.

It's also a diversion of resources. And here the pharmaceutical industry comes in for particular criticism. Ray Moynihan and colleagues accuse it of "extending the boundaries of treatable disease to expand markets for new products" (p 886). Barbara Mintzes echoes this in her argument against direct to consumer advertising of drugs (p 908). In 1999 Americans saw an average of nine prescription drug adverts a day on television, portraying the dual message of a pill for every illand "an ill for every pill." Nevertheless, Silvia Bonaccorso and Jeffrey Sturchio manage a spirited defence of "liberalised direct to consumer information" (p 910).

Indeed, this issue isn't all one sided. Shah Ebrahim asserts that the medicalisation of old age should be encouraged because treating the health problems of older people is effective and attempts to ration care on the grounds of age are unfair (p 861).

And though doctors are accused of encouraging or at least colluding in medicalisation, the alternative view that doctors are just as much its victims is also prominent. "The bad things of life: old age, death, pain, and handicap are thrust on doctors to keep families and society from facing them," say Leonard Leibovici and Michel Lièvre (p 866). "There is a boundary beyond which medicine has only a small role." When doctors are forced to go beyond it "they do not gain power or control: they suffer."

That might suggest that Illich has won the argument. Indeed, David Clark, in his article on the "postmodern specialty" of palliative medicine, thinks he has (p 905). In the 1970s he says, there was a "much more unitary and optimistic view of medicine. Now the . . . system is pervaded with doubt, scepticism, and mistrust."

Footnotes

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