OMG Digital Magazine OMG Issue 335 13th December 2018 | Page 24

OMG Digital Magazine | 335 | Thursday13 December 2018 • PAGE 24
The role of medicine in society
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[1] 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.