In recent years, medical science has faced numerous criticisms. Some critics claim "https://www.allenandunwin.com/browse/books/general-books/current-affairs-politics/Selling-Sickness-Ray-Moynihan-argue</a> that fictitious disease categories are being created, and existing ones broadened, for profit. Others https://www.scientificamerican.com/article/an-epidemic-of-false-claims/" argue that the benefits of most new drugs are minimal and often exaggerated by clinical research, while the harms are significant and typically downplayed. Additionally, some https://www.penguinrandomhouse.com/books/3901/the-truth-about-the-drug-companies-by-marcia-angell-md/ criticize the research methods themselves, stating that methods once considered gold standards in clinical research—randomized trials and meta-analyses—are actually flexible and have been manipulated to favor industry interests over patient care. The chief editor of The Lancet medical journal summarized these criticisms in 2015: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60696-1/fulltext"
Plagued by studies with limited sample sizes, minimal effects, flawed exploratory analyses, and blatant conflicts of interest, along with a fixation on following trendy but questionable topics, science has veered into obscurity.
These issues stem from several structural aspects of medicine. A key one is the profit motive. The pharmaceutical industry is highly lucrative, and the significant financial rewards from drug sales incentivize some of the aforementioned practices. Another significant aspect of medicine is the expectation and hope of patients for medical assistance, paired with the training of doctors to intervene actively through screening, prescribing, referring, or surgery. Additionally, the complex causal basis of many diseases complicates the effectiveness of interventions – treating a simple bacterial infection with antibiotics is one thing, but using antidepressants for depression is quite another. In the author's book https://global.oup.com/academic/product/medical-nihilism-9780198747048?cc=us&lang=en& , these arguments are compiled to conclude that the current state of medicine is indeed troubled. How should medicine address these issues? I introduced the term ‘gentle medicine’ to describe several changes that could be implemented in medicine, with the hope of alleviating these problems. Some elements of gentle medicine might involve minor adjustments to routine practices and current policies, while others could be more transformative.
Let’s begin with clinical practice. Physicians could adopt a less interventionist approach than they currently do. Of course, many doctors and surgeons are already conservative in their therapeutic strategies, and I suggest that such therapeutic conservatism should become more widespread. Similarly, patients' hopes and expectations need to be managed carefully, as advised by the Canadian physician William Osler (1849-1919): ‘One of the first duties of the physician is to educate the masses not to take medicine.’ Treatment should generally be less aggressive and more gentle, when possible.
Another aspect of gentle medicine concerns how the medical research agenda is set. Most research resources in medicine are owned by industry, and its profit motive fuels the ‘obsession for pursuing fashionable trends of dubious importance’. It would be beneficial to have more experimental antibiotics in development, and high-quality evidence on the effectiveness of various lifestyle factors in managing depression (for instance). Similarly, it would be beneficial to have a malaria vaccine and treatments for what are sometimes called ‘neglected tropical diseases’, whose disease burden is substantial. The current coronavirus pandemic has highlighted how little we know about some basic but crucial questions, such as virus transmission dynamics, the impact of masks on disease transmission, and the types of social policies that can effectively flatten epidemic curves. However, there is little industry profit to be gained from pursuing these research programs. Instead, significant profit can be made by developing ‘me-too’ drugs – new versions of a class of drugs for which multiple versions already exist. A new selective serotonin reuptake inhibitor (SSRI) could generate substantial profit for a company, though it would offer little benefit to patients, given that many SSRIs are already on the market (and, in any case, their demonstrated effect sizes are very modest, as I argued in a recent Aeon https://aeon.co/essays/the-evidence-in-favour-of-antidepressants-is-terribly-flawed essay). A proposed policy-level change, advocated by some, is to reduce or eliminate intellectual property protection for medical interventions. This would have several consequences. It would, obviously, diminish the financial incentives that seem to be corrupting medical science. It would likely also mean that new drugs would be cheaper. The actions of individuals like Martin Shkreli would certainly be impossible. Would this also mean less innovative medical research and development? This is a common argument used to defend intellectual property laws. However, it has significant flaws. The history of science demonstrates that major scientific revolutions typically occur without such incentives – consider Nicolaus Copernicus, Isaac Newton, Charles Darwin, and Albert Einstein. Breakthroughs in medicine are no different. The most significant breakthroughs in medical interventions – antibiotics, insulin, the polio vaccine – were developed in social and financial contexts vastly different from today’s pharmaceutical profit-driven environment. Those breakthroughs were genuinely effective, unlike many of today’s blockbuster drugs. Another policy-level change would be to separate the testing of new pharmaceuticals from those who profit from their sale. Several commentators have argued for independence between the organization that tests a new medical intervention and the one that manufactures and sells it. This could help raise the evidential standards for medical interventions, enabling us to better understand their true benefits and harms.
Returning to the research agenda, we also need more rigorous evidence about gentle medicine itself. We have a wealth of evidence about the benefits and harms of initiating therapy – the focus of most randomized trials today. However, we lack rigorous evidence on the effects of discontinuing therapy. Since part of gentle medicine calls for greater therapeutic conservatism, we need more evidence on the effects of stopping medication.
For example, in 2010, researchers in Israel https://www.ncbi.nlm.nih.gov/pubmed/20937924 implemented a drug discontinuation program for a group of elderly patients taking an average of 7.7 medications. By strictly adhering to treatment protocols, the researchers withdrew an average of 4.4 medications per patient. Only six drugs (2 percent) were re-administered due to symptom recurrence. No harms were observed during the drug discontinuations, and 88 percent of the patients reported feeling healthier. We need much more evidence like this, and of higher quality (randomized, blinded). Gentle medicine doesn’t imply easy medicine. We might discover that regular exercise and healthy diets are more effective than many pharmaceuticals for a wide range of diseases, but regular exercise and healthy eating are not easy. Perhaps the most crucial health-preserving intervention during the current coronavirus pandemic is ‘social distancing’, which is entirely non-medical (as it doesn’t involve medical professionals or treatments), although social distancing entails significant personal and social costs. In summary, as a response to the numerous problems in medicine today, gentle medicine proposes changes to clinical practice, the medical research agenda, and policies related to regulation and intellectual property.
Jacob Stegenga
This article was originally published at Aeon and has been republished under Creative Commons.
Comentários