Editorials

Medicalisation: peering from inside medicine

Professionals and lay people should work together to a common purpose

Who benefits and who stands to lose from unnecessary medical procedures or from medicalisation of daily life events? When George Bernard Shaw's Cutler Walpole operates on Lady Gorran and extirpates her nuciform sac he gains not only 500 guineas but also reassurance never to be in doubt or at loss.¹

The medicalisation of life domains is assumed to benefit the medical establishment or the medical professionby giving them power and control. It is an "appropriation" of pregnancy and childbirth,² or of natural death.³ By defining the type A personality, mainstream medicine redefined a masculine behaviour that was once valued.⁴ Such redefinition is a thing of power. It is not difficult to read within Michel Foucault's lines that people who incarcerate others for "madness" gain power and control.⁵

In a department of medicine or obstetrics, things look less simple. A 92 year old woman is admitted to a department of medicine because she refuses to eat and drink. She speaks little and peeps between the folds of the blanket. Her sons talk in terms of depression, brain tumour, rare diseases; her physician talks in terms of old age, her home, her own room. Day by day the sons are more abusive. The physician gives in and does a series of tests. The physician is frustrated and angry: she does nothing good to the patient, but some harm.

An old man has attempted suicide with digoxin. The psychiatrist finds nothing wrong with his psyche but writes that the patient's intentions to commit suicide were serious. The family, social worker, and the legal adviser of the hospital concur that the patient should be restrained in bed. The physician is the one to write the order. On the day the patient is extubated he tells his story. He is lonely, sick, and in pain. His wife died and he is disappointed with his daughters. He wants to die. Because the physician fears litigation, he renews his order of constraint. He knows that he has done wrong.

The family of a 60 year old man with terminal metastatic cancer refuses to take him back home. His pains are well controlled, and they know that nothing more can be done for him. But we cannot conceive that he will die at home, they say. The task to comfort and cope with the dying man is left to the doctor, who has known him less than a week.

In France, a child is born with severe handicap caused by rubella contracted by his mother early in pregnancy. After years of debate (the "Perruche case") France's highest court finally rules that the child can sue his mother's doctors because they had failed to inform her correctly that she was not immunised against rubella, therefore denying her the choice of an abortion. ^{6 7} Doctors fear that they can now be condemned for not being able to predict handicap with 100% certainty.

These aspects of medicalisation make doctors miserable. The bad things of life: old age, death, pain, and handicap are thrust on doctors to keep families and society from facing them. Some of them are an integral part of medicine, and accepted as such. But there is a boundary beyond which medicine has only a small role. When doctors are forced to go beyond that role they do not gain power or control: they suffer.

What can be done to protect the public, but also the doctors, from the bad aspects of medicalisation? We can turn to Shaw for advice.¹ Do not turn doctors into tradesmen, he says. The medical profession should become "a body of men trained and paid by the country to keep the country in health." But pay them well.

What the public wants, says Shaw, is "a cheap magic charm to prevent, and a cheap pill or potion to cure all diseases." Sometimes it looks as if death and old age are included among these diseases. Both the public and the medical profession should know that doctors are not infallible and they do not produce magic. It is almost trivial to say that. What can be done to define the boundaries, to reach a rational discourse between the public and the medical profession? A step in the right direction might be associations in which professionals and lay people work together to a common purposefor example, to find which treatments are efficient and acceptable and to promote these treatments.

Legislation is another solution. Clear legal boundaries for end of life dilemmas, for example, will help both the public and doctors. The French National Assembly recently challenged the "right to have never been born" after the Perruche case.

A major actor in the modern doctors' dilemma is the press. The press often trumpets magic curesfor example, to end all painand fiendish doctors. Terms such as limitations and uncertainty should be introduced to the press. A meeting ground to introduce such terms might be the interaction between the medical and the lay press.

And, finally, another piece of advice from Shaw: "Make it compulsory for a doctor using a brass plate to have inscribed on it, in addition to the letters indicating his qualifications, the words `Remember that I too am mortal.' "

Leonard Leibovici, professor. 

Department of Medicine, Beilinson Campus, Rabin Medical Center, 49100 Petah-Tiqva, Israel(leibovic{at}post.tau.ac.il)

Michel Lièvre, professor. 

Clinical Pharmacology Unit, BP 8071, Faculté RTH Laënnec, rue Guillaume Paradin, 69376 Lyon, Cedex 08, France(ML{at}upcl.univ-lyon1.fr)