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Concepts of health, wellbeing and illness, and the aetiology of illness: Section 8. The role of medicine in society
This section covers:
1. Challenging biomedicine and iatrogenesis
2. The antipsychiatry movement
3. Patients as active consumers
1. Challenging biomedicine and iatrogenesis
The role of medicine has been described as ‘to cure sometimes, to heal often and to comfort always’. As definitions of health have expanded, so have the roles of healthcare professionals and organisations, with more and more aspects of life associated with medical intervention (see section 7). More recently the dominance of biomedicine has been called into question, and its role in society has been challenged. Part of this shift is due to increasing awareness of unintended consequences of prescription drugs - not just from the point of view of side effects and clinical iatrogenesis, but the impact on wider societies and healthcare systems.
For individuals, particularly older people with multiple conditions, there is increasing awareness of the risks around polypharmacy. This is where drugs are prescribed to counteract the side effects of other drugs, e.g. painkillers for drugs that have headaches as a side effect; as well as presenting risks of further side-effects to patients (much like the old lady who swallowed a fly), it also increases the cost burden to healthcare systems. On a societal scale, the overprescribing of antibiotics is believed to have contributed to the current antimicrobial resistence (AMR) crisis, and doctors are now being encouraged to not prescribe antibiotics when they are likely to be ineffective, i.e. for colds and other viral infections.
However, prescribing is an area where evidence-based indicators of quality and safety may diverge from patient preferences. Research has shown that patient satisfaction may be influenced negatively by not receiving a prescription when they expect to do so (Coenen et al., 2013; Zgierska et al., 2012). Moreover, clinicians may overestimate these expectations and over-prescribe medications that they perceive to be harmless to avoid damaging the doctor-patient relationship (Coenen et al., 2013). The dilemma presents a challenge to the concept of patient-centred care, raising the question of how patient experiences and priorities should be balanced against clinical judgement.
In 2002 the BMJ published a themed issue on overmedicalisation, with a number of articles discussing the physical, mental and social consequences of overdiagnosis and overprescribing. Changes in social constructs of health and illness and the role of medicine in society were underlying themes throughout the issue. It was argued that modern medicine was undermining the capacity of individuals to cope with death, pain and sickness (Moynihan, 2002 - as per Illich, 1976), and that doctors were colluding in overmedicalisation by trying to protect patients and the public from having to face the ‘bad things in life’ (Leibovici & Lièvre, 2002). The pharmaceutical industry was blamed for expanding treatment boundaries in order to sell more products, and for promoting both ‘a pill for every ill’, and ‘an ill for every pill’ (Mintzes, 2002). The BMJ’s Too Much Medicine campaign aims to address these issues by highlighting the threat of overdiagnosis and overprescription to human health and NHS sustainability, advocating a reduction in unnecessary tests and treatments. The definition of ‘unnecessary’ is nonetheless contentious in itself, as perspectives may differ within and between professional and patient groups.
Today there is much focus on medicine optimisation, which is about ensuring that the right patients get the right choice of medicine, at the right time. A recent report by the King’s Fund identified good medicines management as one of the key priorities for health service commissioners (Naylor et al., 2013). Approaches include the use of decision support tools and regular medicine reviews. Effective medicines management has been found to improve outcomes for patients by reducing likelihood of errors, increasing compliance with treatment, and facilitating self-care. Good communication between doctors and patients can help to manage expectations and increase shared decision-making (Chewning & Sleath, 1996; Zolnierek & Dimatteo, 2009). The National Institute for Health and Care Excellence (NICE; 2013) summarises the evidence base for key therapeutic areas in medicines management, including antibiotics and hypnotics.
2. The anti-psychiatry movement
From a mental health perspective, the anti-psychiatry movement has challenged the medical or psychiatric model of treatment, and perhaps represents the biggest challenge to biomedicine. The work of the Scottish psychiatrist R.D. Laing during the 1960s and 1970s is most often associated with the antipsychiatry movement, although Laing himself did not reject the value of treating mental distress. He did, however, question the concept of mental illness as a medical phenomenon, instead framing it as a valid reaction to lived experience rather than a symptom of underlying pathology. According to Laing, the problem was with society, not the individual: “Insanity is a legitimate response to so-called 'sane' society. In effect, society is sick” (Laing, 1967). While many regarded him as a ‘dangerous charlatan’, others saw him as a champion for the mentally ill. It has been suggested that Laing’s greatest contribution was to bring humanity to the treatment of psychiatric patients, and to identify the dehumanising nature of traditional approaches - which is applicable to all areas of medical practice (Clare, 1990; Beveridge, 1998).
Despite the anti-psychiatry movement, the biomedical model remains the dominant model of care for people with mental illness. Nevertheless, concerns about overmedicalisation within psychiatry are becoming more common. Double (2002) asserts that although psychiatry can be effectively applied when appropriate, practice should move away from biomedicine and towards a biopsychosocial approach. He argues that as expectations of solutions to mental health problems rise, the more pharmaceutical treatment is seen as a panacea, and the more personal and social problems are neglected. Similar issues were raised with the publication of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) in 2013. This proposed a number of new diagnoses and lowered thresholds for a number of others, leading to concerns about an increase in ‘false positive’ diagnoses or the pathologisation of normal states such as grief (e.g. Frances, 2010;2013).
3. Patients as active consumers
Patients themselves represent a challenge to the biomedical model as access to means of self-care increases, and dependence on clinicians decreases. The explosion of available information via the internet means that people are able to make more informed decisions about whether to see a doctor, and in some cases which doctor to see. The availability of over-the-counter treatments for common ailments has increased, and many services such as diagnostic tests are now available without referral or medical approval. There has also been a rise in the popularity of alternative therapies (i.e. those used instead of conventional healthcare) and complementary therapies (i.e. those used alongside conventional healthcare). These include practices such as massage, acupuncture and homeopathy.
Self-care has been greatly encouraged in the UK with the increased emphasis on patient-centred care and the importance of patient satisfaction as an indicator of quality (see Section 2). As well as increasing patient autonomy, it also relieves the burden on health services as the population grows and ages. However, some have raised concerns that this approach has shifted responsibility for care too far onto patients, who may not be equipped to manage the vast volume of information to make the right decisions about their care. This undermines the purpose of patient-centred care, which is to facilitate dialogue and shared decision-making between doctors and patients (e.g. Meill & Ericson, 2012).
The value of alternative and complementary approaches has also been contested. Homeopathy, for example, has no reliable evidence supporting a clinical effect, and may actually harm health if used as an alternative to treatments known to be effective. However, while few in the field of healthcare would argue to the contrary, what constitutes ‘value’ is not always the same for patients and clinicians. A survey of patients in the US found that most patients seemed in favour of placebo prescriptions, provided that clinicians were open and transparent about what they were prescribing (Chandros Hull et al., 2013). Although it is often assumed that use of placebo is deception by definition and therefore removes patient autonomy, it has been demonstrated that placebo effects can happen even when patients are aware that they are taking a placebo (Finniss et al., 2010). Within publicly funded healthcare systems such as the NHS, however, this raises a further ethical issue by diverting funds from treatments known to be effective, and potentially undermines the principle of evidence-based care.
© I Crinson 2007, Lina Martino 2017