March 2014
Source: Revista Clinica Espanola
Photo Source: Unsplash, Jusdevoyage
Abstract Western societies are characterized by a growing medicalization of life events, such as pregnancy, aging, or even death. Three concepts -medicalization, wish-fulfilling medicine, and disease mongering- are key in understanding the current practise of Medicine. Quite surprisingly, not a single study has addressed the relationship between all three of these concepts. The term medicalization expanded under the open-ended concept of health developed by the World Health Organization in 1946. One of the consequences of medicalization is the transition from patients to clients. Physicians are under increasing pressure to meet the insatiable demands of their clients. The term wish-fulfilling medicine refers to the increasing tendency of medicine to be used to fulfill personal wishes (i.e. enhanced work performance). The insatiable demand for healthcare is troublesome, particularly in Europe, where the welfare states are more and more under pressure. Finally, the term disease mongering refers to attempts by pharmaceutical companies to artificially enlarge their “markets” by convincing people that they suffer from some sickness and thus need medical treatment. Typical examples of disease mongering are social anxiety disorder, low bone mineral density, and premature ejaculation. Currently, some Public Health Services could be on the brink of collapse as they “navigate” between the scarce resources available and the users’ insatiable health demands. Therefore, it appears necessary to generate clear-cut Public Health Services Port-folios.
Introduction “[…] He remained obstinately gloomy the whole afternoon; wouldn’t talk to Lenina's friends (of whom they met dozens in the ice-cream soma bar between the wrestling bouts); and in spite of his misery absolutely refused to take the half-gramme raspberry sundae which she pressed upon him. “I’d rather be myself,” he said. “Myself and nasty. Not somebody else, however jolly.”Brave new world- Aldoux Huxley
The limits of current Medicine are becoming more and more blurred as increasingly more advances are made. Our focus begins to shift from what can we treat to what should we do treat as doctors. Aldous Huxley, a seminal author of the 20th Century, predicted the medicalizationof life events. For instance, unhappiness is nowadays treated with antidepressants. We could speculate about which is our soma (the ideal pleasure drug taken by everybody in Aldous Huxley’ famous novel Brave New World) nowadays, but we do not need to look far: the prescription of antidepressants has tripled from 1994 to 2003 in Spain.1 Two atypical antipsychotics, aripiprazol (Abilify®, Otsuka, Bristol-Myers Squibb) and quetiapine (Seroquel®, AstraZeneca), and one antidepressant (Duloxetine, Cymbalta®, Eli Lillly) are among the ten best selling prescription drugs in the U.S.
This might lead one to think that massive soma-medication of the population has already occurred. Has the medicalization of everyday problems gone too far?
People are using novel medications in dangerous ways; for example, some adolescents use cognitive enhancers to improve cognitive function and some have even died in the aftermath of Viagra® use. On the other hand, the pharmaceutical industry is very interested in developing mood brighteners or happiness pills to meet increasing demands. And the lack of a prescription is hardly a problem anymore because you can easily get what you want at a modest price delivered to your door thanks to the Internet.
In this context, it is complicated to understand current Medicine without using three concepts: medicalization, wish-fulfilling Medicine, and disease mongering. Quite surprisingly, there are no previous studies addressing the relationship among all three concepts. The concept of medicalization gained importance in the seventies, and it can still be considered a classical term in Sociology and Medicine. In the eighties, researchers began to speak about wish-fulfilling medicine. Lastly, the first article on disease mongering indexed in the PUBMED was published in 2002. Could this latest interest on disease mongering reflect the preoccupation of researchers on the type of medically controlled societies we are creating? Are we headed toward a brave new world?
Medicalization: from patients to clients Western societies are characterized by a growing medicalization of life events such as puberty, menopause, pregnancy, aging, or even death.2 The term medicalizationrefers to problems previously regarded as normal or as a deviance of normal that are now regarded as “pathologized” life events, such as menopause, baldness, or marital separation.3 Specifically, medicalization can be defined as “a process by which nonmedical problems become defined and treated as medical problems, usually in terms of illnesses or disorders”.4
Although it is difficult to establish when this term entered the social and medical vocabulary,5 its use expanded under the open-ended concept of health developed by the WHO in 1946 that stated that “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.6 This supposed a Copernican change, as the traditional concept of health, based on the presence/absence of illness -the medical science behind the traditional medical model has evolved through five stages: (1) symptoms, (2) syndromes, (3) tissue alterations, (4) demonstration of the causes behind these tissues alterations, and (5) treatment,7 was replaced by “a state of complete physical, mental and social well-being”. In other words, happiness.
One of the areas where medicalization is clearly represented is aging and death. Life expectancy at birth is growing worldwide, particularly in industrialized countries. Even though it is still currently impossible to change our genetic code in order to live longer, we are not far from this possibility. For instance, modification of the daf2 gene can double the life span of worms.8 The possibility of extrapolating these advances to human beings has raised serious ethical concerns.9 But, not everyone concerns. The American futurist Ray Kurweil has paid for his cryopreservation along with more than 800 millionaires just in case these advances are not in the foreseeable future.
Medicalization is also rooted in the field of mental disorders. For instance, individuals lacking personal resources to face certain life events (i.e. marital discord) are displacing the “usual” psychiatric patients (i.e. those with schizophrenia). Indeed, adaptive disorders are the most frequent disorders in public mental health centers in the Community of Madrid (Spain).10 Another example is the medicalization of deviances, such as, hyperactivity and learning disabilities.4 Conrad stressed that there were no hyperactive children in the People's Republic of China in the seventies whereas ten years later hyperactivity became the most prevalent diagnosis.4
Some of the forces behind medicalization are pharmaceutical companies economic interests, but they do not stand-alone. Physicians are being increasingly pressured by the insatiable demands of their patients (or users).3 Indeed, one of the consequences of medicalizationis the transition from patients to clients (users). Clients are more pro-active in making decisions with regards to their medicalized desires; in essence, physicians become just a tool for fulfilling their wishes. Finally, there are also socio-political reasons explaining the extension of medicalization.5
For instance, the transition from public health care services to private health care services fits perfectly well with the transition from patients to clients, as new health users have consumer mentalities.
Wish-fulfilling medicine: law of desire What do people strive for in the 21st Century? High paying jobs, money, time, to look better, to feel comfortable, pleasure, etc.
Thus, it is not surprising the increasing tendency for medicine to be used to fulfill personal wishes (i.e. better social skills, enhance work performance).11 Wish-fulfilling medicine can be defined as “doctors and other health professionals using medical means (medical technology, drugs, etc.) in a medical setting to fulfill the explicitly stated, prima facie non-medical wish of a patient”.11 In contrast to patients, wish-fulfilling clients choose the treatment they receive from the first consultation, rather than their doctors. Thus, the role of the physician becomes that of a technician.11
Buyx defended that fulfilling the wishes of competent people is morally neutral11; however, she rejected the idea of including wish-fulfilling medicine in standard medical care,11 and I concur. The problem with wish-fulfilling medicine is that the demand for healthcare is insatiable. This is troublesome particularly in Europe where the welfare states are more and more under pressure.
The development of wish-fulfilling medicine, a term coined by Matthias Kettner,12 is probably a reflection of what is happening in our societies. “Traditional” patients, those who sensu stricto have diseases, demand their physicians to restore them to their previous healthy state. On the other hand, “new” clients come to their physicians demanding solutions for problems that are not considered diseases (e.g. baldness). Unfortunately, the problem here is that it is not an easy task to delineate the definition of disease that can evolve and change with regard to different socio-cultural contexts.2 In this context, there are an increasing number of health issues that could be included within the concept of wish-fulfilling medicine. Reproductive medicine or plastic surgery are two classic examples of wish-fulfilling medicine.12 For instance, more than half of the genetic pre-implantation diagnoses in the U.S. are not motivated by therapeutic issues but by gender selection
Disease mongering: gas lighting? The concept of disease mongering was first defined by Lynn Payer in the 90s and refers to the attempts made by pharmaceutical companies to artificially enlarge the “market” by convincing people that they suffer from some sickness and need medical treatment.13 Since pharmaceutical companies are under constant pressure to maintain sales growth, the temptation to expand the range of “diseases” treatable by a present commercialized product via marketing may be too strong.14
Typical examples of disease mongering are social anxiety disorder, low bone mineral density, restless legs, premature ejaculation, and female sexual dysfunction, among others.14 Psychiatry is one of the medical disciplines more vulnerable to disease mongering,15specifically because Psychiatry lacks objective data (i.e. biomarkers) for diagnosing disorders.
Disease mongering is nowadays more frequent because we are living in the Internet era. This means that “we have access to more information and more quickly than ever before in human history”, and Internet sites are the way people develop social networks.16 In other words, it is easier than ever to create novel diseases and to disseminate information on them.13 News media are key in the dissemination of these new diseases.14 For example, the emergence of the Internet may help to explain why fibromyalgia, a clinical entity that was recognized in the 1990s by the American College of Rheumatology17 and apparently suffered by 2–3% of the general population,18 did not previously create a huge social alarm.
Conclusion There has been a Copernican change in the concept of health since the post-world war II WHO definition of health. Wish-fulfilling medicine is usually placed within private practise, but the limits between “traditional” medicine and wish-fulfilling medicine are not always clear.12 This is particularly worrying nowadays, given that some Public Health Services could be on the brink of collapse, as they “navigate” between the scarce resources available and the users’ insatiable health demands. Therefore, it appears there is a necessity to generate clear-cut Public Health Services Port-folios placing wish-fulfilling medicine within the limits of private practise.
It appears as if we were going toward a brave new world. However, it is important to erase any kind of fatalism: the process of medicalization is by no means stationary and can be challenged. Modern western societies are characterized, among others, by the satiety of senses and the lack of frustration. We thought that this vacuous superabundance would make us happier. But this has not been true. Desire, like Eros, appears to be insatiable. Instead, boredom is our punishment. It is possible that Zygmunt Bauman was right: in the inherent nature of desire is written its self-destruction.19
Conflict of interest Dr. Blasco-Fontecilla has received lecture fees from Eli Lilly, Shire, and AB-Biotics in the last three years.
Acknowledgments
Dr. Blasco-Fontecilla thanks Victoria de Leon-Martinez for English editing.
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