Promoting diseases to promote drugs -- the role of pharmaceutical industry in fostering good and bad medicalization

Pharmaceutical industry and drugs advertisement is sometimes accused of “creating diseases”. This article assesses and describes the role of that industry in fostering medicalization. First, the notions of medicalization and pharmaceuticalization are defined. Then, the problem of distinguishing between harmful overmedicalization and well-founded medicalization is presented. Next, the phenomenon of disease mongering is explained and illustrated by the case analysis of medicalizing pain and suffering in three contexts: 1) the general idea of medicalizing physical pain, 2) the medicalization of grief, and 3) disease mongering of pseudoaddiction - a condition promoted in order to increase the demand for opioid pain relievers.

Prävention von Fehl- und Überversorgung

Zusammenfassung. Fehl- und Überversorgung wird pragmatisch als eine Versorgung definiert, deren potenzieller Schaden den Nutzen überwiegt (Fehlversorgung), oder die über den nötigen Bedarf hinausgeht (Überversorgung). Sie ist eine Herausforderung für Patienten, Betreuer, Politiker und Gesundheitssysteme. Auch in der Schweiz gibt es Fehl- und Überversorgung, wie die nähere Betrachtung von diversen diagnostischen Methoden und therapeutischen Eingriffen zeigt. Die Auslöser von Fehl- und Überversorgung sind vielfältig: Zum Beispiel ermöglicht der technische Fortschritt eine immer frühere Entdeckung von Krankheit, ohne dass dies immer einen Nutzen für den Patienten bedeutet (Überdiagnose). Weitere Gründe sind organisatorische Defizite, angebotsgesteuerte Nachfrage, kommerziell motivierte Erweiterung des Krankheitsbegriffes (disease mongering) und der Einfluss von soziokulturellen Überzeugungen. Entsprechend ist es keine einfache Aufgabe, Fehl- und Überversorgung zu bekämpfen. Als Antwort sind in den letzten Jahren diverse Konzepte und Kampagnen entwickelt worden, wie Quartäre Prävention, Choosing Wisely oder Preventing Overdiagnosis. Deren Ziel ist es, Individuen vor medizinischen Interventionen zu schützen, die mit hoher Wahrscheinlichkeit mehr Schaden als Nutzen anrichten. Was kann die Hausärztin, der Hausarzt zur Prävention von Fehl- und Überversorgung beitragen? Erstens, das Bewusstsein für solche unangemessenen Interventionen zu schärfen und offen dafür zu sein, die eigene professionelle Einstellung kritisch zu hinterfragen. Zweitens hat die Hausärztin, der Hausarzt als Vertrauensperson für den Patienten die einzigartige Gelegenheit, mit ihr / ihm Schaden und Nutzen einer Intervention abzuwägen und in einer partizipativen Art zu diskutieren (Shared Decision Making). Dabei können Techniken wie Team Talk, Option Talk und Decision Talk gewinnbringend zum Einsatz kommen. Zusammenfassend ist der Schutz unserer Patienten vor Fehlversorgung, Überversorgung und Schaden ein wichtiger Teil unserer professionellen Performance.

A disforia de gênero como síndrome cultural norte-americana

Resumo: O diagnóstico “disforia de gênero”, proposto pela quinta edição do Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM-5), é apresentado como uma “síndrome cultural” norte-americana, ilustrando a tendência expansionista da American Psychiatric Association (APA) em arregimentar as experiências de trânsito de gênero que escapem à matriz de inteligibilidade centrada em torno do masculino/feminino. A esse diagnóstico, forjado pelo pensamento binário estadunidense, nos moldes da chamada disease mongering, opõe-se a experiência da travesti brasileira como alteridade radical para com a matriz de inteligibilidade de gênero instituída.

Effectiveness and Medicalization

This chapter further articulates the hybrid account of effectiveness presented in Chapter 2 and applies it to several pressing problems with disease attribution. A medical intervention can act at several physical scales or levels; it is at least pragmatically useful to think of some of our most effective medical interventions (‘magic bullets’) operating at microphysiological levels. A medical intervention can be effective to varying degrees of generality, though ultimately what matters for the typical patient is whether or not an intervention will be effective for that patient. The hybrid account of disease affords a critical stance on several troubling phenomena in medical science, including medicalization or ‘disease-mongering’ and overdiagnosis and overtreatment. The chapter ends by addressing several objections that might be raised against the hybrid account of effectiveness presented in Chapter 2 and its further articulation and application here.

Overdiagnosis: An unrecognised and growing worldwide problem in healthcare

Overdiagnosis is the diagnosis of deviations, abnormalities, risk factors, and pathologies that in themselves would never cause symptoms (this applies only to risk factors and pathology), would never lead to morbidity, and would never be the cause of death. Therefore, treating an overdiagnosed condition (deviation, abnormality, risk factor, pathology) cannot, by definition, improve the patient’s prognosis, and can therefore only be harmful. Overdiagnosis is an extremely harmful and big problem all over the world, and the problem is increasing. This is especially the case in high-income countries, where more sensitive tests, more testing, more screening and earlier diagnosis is in focus, and more of the same will be implemented in the future. Moreover, disease definitions have been and are still being widened, plus thresholds for treating, e.g. risk factors, have been and are still being lowered. Finally, disease mongering is growing, because it is cheaper and faster to invent new “diseases” than new pharmaceutical drugs. From the definition of overdiagnosis it can be reasoned that a patient who has been correctly diagnosed and a person who has been overdiagnosed can have the same kind of pathologies. Therefore, at the level of the individual person or patient it can never be verified whether he or she has in fact been correctly diagnosed or overdiagnosed. Therefore, the complexity, dilemmas and pitfalls in understanding what overdiagnosis really is so succinctly captured by this quote from the Danish philosopher S⊘ren Kirkegaard (1813-55): ‘Life can only be understood backwards; but it must be lived forwards’.