EDITORIAL

The growing medicalization of life: Are physicians aware of the damage it causes?

http://dx.doi.org/10.5546/aap.2012.459

Medicalization of life and death is not recent and in the West it probably started at the end of the 18th century, together with the development of the emerging science, continuing in the 19th century and remarkably in the 20th century. However, in the last 50 years it has been more and more prominent and what is striking is that there are no signs that its growth is diminishing nor showing a trend towards decreasing. However, there are physicians and other healthcare providers, as well as professionals from other fields, especially that of the Social Sciences, who are really concerned about the scope of this process and its damaging effects both on people's lives and on the medical profession.
I will herein try to emphasize why this phenomenon is in no way harmless and, at the same time underscore that for us, physicians, it is critical to ponder about it, since undoubtedly it is distant from the goals of medicine and the moral and ethical principles of our profession.

How do we define medicalization?
The answer is not easy nor is there a single definition that includes all its facets and a detailed description of its great complexity. Simply, it would be the expansion of medicine beyond its traditional field and its presence in multiple aspects in people's lives, which until recently were not considered within the medical realm. Thus, mild and occasional discomforts become diseases and the same occurs with different processes, among others: old age, unhappiness, loneliness, sadness, abandonment, isolation, unemployment, etc., which enter the medical sphere. Since any disorder can be considered a disease and therefore, in the medical practice, physicians who suppose healthy patients are "sick people badly studied" are on the rise, which markedly increases mercantilism through the excessive use of medications and request for studies.
All this represents a remarkable change in the approach to natural processes of the vital cycle by exclusively considering them as medical or psychological issues. It is quite likely better results could be obtained if these processes were not included in the field of medicine.
Thus a non-medical problem becomes a medical issue, is described in medical language and has a medical reference framework, producing adverse effects on people.
Medicalization began to be considered as non-desirable when analyzed from a social perspective for being something that was strongly influencing society cultures and habits. The English writer G. K. Chesterton in his book What's wrong with the world included in the first part, titled "The homelessness of man", an essay called "The medical mistake" (Complete works. J Janés, Barcelona, 1952) pointing out the fallacy of certain scientific arguments that through the comprehensive description of a social illness later proposed the corresponding medication.
This process, in which medicine and doctors "invade" fields alien to their discipline, gained further notoriety with the Austrian philosopher Ivan Illich in his book Medical Nemesis (Ed. Barral,1975). Illich was a harsh critic of medicine and doctors and while many of his concepts are controversial, there is no doubt he was one of the first to point out what was later called "the hegemonic medical model" in reference to the power of medicine to include alien things in its environment so as to become omnipresent in people's lives. This stimulated the increasingly medicalization based on people's erroneous belief about the deification of physicians by which medicine could solve all or the great majority of their problems. It is interesting to point out that in Greek mythology nemesis was the punishment for those who intended or believed to be gods instead of human beings.
In medicalization there are at least two main players, first we, the doctors, and then society, more and more addicted to novelty and anxious for medicine to use its power to satisfy the growing obsession of obtaining perfect health and a"forever young" body. This is more remarkable in Western developed countries, though it is expanding to countries with more limited resources, resulting in one of the most critical problems; that is, healthcare inequality.
Likewise, another deleterious result of its expansion is the creation of new diseases or disorders to increase the consumption of unnecessary drugs and diagnostic methods. Four players take part in this process, the main ones are doctors and the pharmaceutical and biotechnological industries, the third one is the consumer society of this era and finally, the erroneous and insufficient public health State policies. This is an extremely complex process that deserves multiple approaches that I will briefly mention without addressing them in depth.
The process responds to a great extent to the conviction of many doctors, and thus of industries (medical-industrial complex) that scientific medicine has an indisputable efficacy and that all its actions are beneficial.
Thus, by going beyond its borders, markets increasingly expand to new products; "in this way, a lot of money can be obtained from healthy persons who think they are sick" (Moynihan, 2002). By and large, people tend to accept this behavior and frequently demand it. From this stems the comment too often heard: "I went to the doctor, who examined me thoroughly but prescribed me no medications nor requested any studies".
Already in the 70s, French philosopher Foucault, who had a very critical position on medicalization, stated: "In medicine wealth is generated to the extent that health is a desire for some and a profit for others".
This medicine goes in hand with the amazing technological development, which for many is the essential foundation for scientific knowledge, with which I don't agree. The "technological era" generated multiple benefits, but also multiple undesirable effects, among them commodization of medicine originating the loss of its original goals and ethical principles. This aspect doesn't happen for technology itself, but for its inadequate use.
The generalized idea in current society that technology can provide a "better and better" life has a pernicious influence and contributes to generate the false premise that progress is endless and unlimited.
Likewise, the increase in drug prescription for all types of conditions, even when it has not been proven to be useful, progressively generates an excessive and, in most cases, unjustified consumption that carries along the risk of adverse effects.
Another aspect is that of screening systems to detect potential present or future disorders. A number of them have evidence of their benefits especially in persons with an increased risk ofdeveloping a disease but others are not soundly supported. In these cases, healthy people are subjected to depend on medical care without evidence that these studies will have an influence on their life expectancy.
This system and the excessive use of ancillary diagnostic methods, so fashionable in the current medical practice, contribute to notably increasing costs, undoubtedly leading to non-sustainable medicine, and also, to the growing profit of stakeholders. As the Argentine philosopher Mario Bunge said, "medicine cannot be for profit, because profit has no limits".
Medicalization of death is also marked. In our culture it is not accepted and is generally a taboo issue. Many resort to medicine to receive indications of diagnostic studies and "miracle" medicines without understanding that death is inevitable and is not only a medical issue. However, medicine participates more and more, and today most people cannot die at home with their loved ones and instead they die at medical centers, frequently in intensive care units without their beloved relatives.
Finally, I will try to answer the question of the title. It is clear that physicians are the main players in medicalization. Without our participation this process would markedly decrease. We must ponder on the harm it causes to people and to our profession and continue struggle to limit its growth and if possible to foster its decrease. Those of us who have devoted many years to the professional practice must lead the recovery and maintenance of the ethical principles that should always be our beacon. It is essential to instill these principles to the youth, starting in college and in the later stages of training.
Of course this is not an easy task but whatever we do, even on a small scale, will result in the prevention or decrease of damage, an essential ethical and moral imperative of our profession. n

José M. Ceriani Cernadas
Editor