Intended for healthcare professionals

Analysis Essay

Role of fear in overdiagnosis and overtreatment—an essay by Iona Heath

BMJ 2014; 349 doi: (Published 24 October 2014) Cite this as: BMJ 2014;349:g6123
  1. Iona Heath, former general practitioner
  1. 1London, UK
  1. iona.heath22{at}

Iona Heath argues that doctors and patients need to face up to their fears of uncertainty and death if we are to control overmedicalisation

In the preface to her influential essay Illness as Metaphor, Susan Sontag wrote:

Illness is the night side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.1

Today the kingdom of the well is being rapidly absorbed into the kingdom of the sick, as clinicians and health services busy themselves in ushering people across this important border in ever increasing numbers. Sontag clearly recognises the discomforts of the kingdom of the sick and the extent to which an imposed citizenship there corrodes the joys of life. Yet her essay was first published in 1978, long before the erosion of the kingdom of the well had begun in earnest. With the rise of neoliberal economics, health became a commodity like any other. The exploitation of sickness, and fears of sickness, for the pursuit of profit increased hugely over the subsequent decades, underpinned by the rapid commercialisation of healthcare.

Now, more than three decades later, fewer and fewer of us find ourselves still holding Sontag’s good passport and ever more are corralled into the kingdom of the sick earlier than ever, and residency there becomes longer and longer. All this is legitimised by being described as an epidemic of chronic illness, although many of those affected have no symptoms whatsoever. The motivation for the invasion is provided by a toxic combination of good intentions, wishful thinking, and vested …

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