How gentle medicine could radically transform medical practice

Has medicine been hijacked by the desire for profit? Jacob Stegenga puts his case.

How gentle medicine could radically transform medical practice

Numerous criticisms of medical science have been articulated in recent years. Some critics argue that spurious disease categories are being invented, and existing disease categories expanded, for the aim of profit. Others say that the benefits of most new drugs are minimal and typically exaggerated by clinical research, and that the harms of these drugs are extensive and typically underestimated by clinical research. Still others point to problems with the research methods themselves, arguing that those once seen as gold standards in clinical research – randomised trials and meta-analyses – are in fact malleable and have been bent to serve the interests of industry rather than patients. Here is how the chief editor of The Lancet medical journal summarised these criticisms in 2015:

Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.

These problems arise because of a few structural features of medicine. A prominent one is the profit incentive. The pharmaceutical industry is extremely profitable, and the fantastic financial gains to be made from selling drugs create incentives to engage in some of the practices above. Another prominent feature of medicine is the hope and the expectation of patients that medicine can help them, coupled with the training of physicians to actively intervene, by screening, prescribing, referring or cutting. Another feature is the wildly complex causal basis of many diseases, which hampers the effectiveness of interventions on those diseases – taking antibiotics for a simple bacterial infection is one thing, but taking antidepressants for depression is entirely different. In my book Medical Nihilism (2018), I brought all these arguments together to conclude that the present state of medicine is indeed in disrepair.

How should medicine face these problems? I coined the term ‘gentle medicine’ to describe a number of changes that medicine could enact, with the hope that they would go some way to mitigating those problems. Some aspects of gentle medicine could involve small modifications to routine practice and present policy, while others could be more revisionary.

Let’s start with clinical practice. Physicians could be less interventionist than they currently are. Of course, many physicians and surgeons are already conservative in their therapeutic approach, and my suggestion is that such therapeutic conservatism ought to be more widespread. Similarly, the hopes and expectations of patients should be carefully managed, just as the Canadian physician William Osler (1849-1919) counselled: ‘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 feasible.

Another aspect of gentle medicine is how the medical research agenda is determined. Most research resources in medicine belong to industry, and its profit motive contributes to that ‘obsession for pursuing fashionable trends of dubious importance’. It would be great if we had more experimental antibiotics in the research pipeline, and it would be good to have high-quality evidence about the effectiveness of various lifestyle factors in modulating depression (for example). Similarly, it would be good to have a malaria vaccine and treatments for what are sometimes called ‘neglected tropical diseases’, the disease burden of which is massive. The current coronavirus pandemic has displayed how little we know about some very basic but immensely important questions, such as the transmission dynamics of viruses, the influence of masks on mitigating disease transmission, and the kinds of social policies that can effectively flatten epidemic curves. But there is little industry profit to be made pursuing these research programs. Instead, great profit can be made by developing ‘me-too’ drugs – a new token of a class of drugs for which there already exist multiple tokens. A new selective serotonin reuptake inhibitor (SSRI) could generate great profit for a company, though it would bring little benefit for patients, given that there are already many SSRIs on the market (and, in any case, their demonstrated effect sizes are extremely modest, as I argued in a recent Aeon essay).

A policy-level change, for which some now argue, is to reduce or eliminate the intellectual property protection of medical interventions. This would have several consequences. It would, obviously, mitigate the financial incentives that appear to be corrupting medical science. It would probably also mean that new drugs would be cheaper. Certainly, the antics of people such as Martin Shkreli would be impossible. Would it also mean that there would be less innovative medical research and development? This is a tired argument often raised to defend intellectual property laws. However, it has serious problems. The history of science shows that major scientific revolutions typically occur without such incentives – think of Nicolaus Copernicus, Isaac Newton, Charles Darwin and Albert Einstein. Breakthroughs in medicine are no different. The most important breakthroughs in medical interventions – antibiotics, insulin, the polio vaccine – were developed in social and financial contexts that were completely unlike the context of pharmaceutical profit today. Those breakthroughs were indeed radically effective, unlike most of the blockbusters today.

Another policy-level change would be to take the testing of new pharmaceuticals out of the hands of those who stand to profit from their sale. A number of commentators have argued that there should be independence between the organisation that tests a new medical intervention and the organisation that manufactures and sells that intervention. This could contribute to raising the evidential standards to which we hold medical interventions, so that we can better learn their true benefits and harms.

Returning to the issue of the research agenda, we also need to have more rigorous evidence about gentle medicine itself. We have a mountain of evidence about the benefits and harms of initiating therapy – this is the point of the vast majority of randomised trials today. However, we have barely any rigorous evidence about the effects of terminating therapy. Since part of gentle medicine is a call to be more therapeutically conservative, we ought to have more evidence about the effects of drug discontinuation.

For example, in 2010 researchers in Israel applied a drug discontinuation program to a group of elderly patients taking an average of 7.7 medications. By strictly following treatment protocols, the researchers withdrew an average of 4.4 medications per patient. Of these, only six drugs (2 per cent) were re-administered due to symptom recurrence. No harms were observed during the drug discontinuations, and 88 per cent of the patients reported feeling healthier. We need much more evidence like this, and of higher quality (randomised, blinded).

Gentle medicine doesn’t mean easy medicine. We might learn 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 important health-preserving intervention during the present coronavirus pandemic is ‘social distancing’, which is completely non-medical (insofar as it doesn’t involve medical professionals or medical treatments), though social distancing requires significant personal and social costs.

In short, as a response to the many problems in medicine today, gentle medicine suggests changes to clinical practice, the medical research agenda, and policies pertaining to regulation and intellectual property.Aeon counter – do not remove

Jacob Stegenga

This article was originally published at Aeon and has been republished under Creative Commons.

Do you believe medicine has been hijacked?

Jacob Stegenga is a reader in philosophy of science at the University of Cambridge. He is the author of Medical Nihilism (2018) and Care and Cure: An Introduction to Philosophy of Medicine (2018). He lives in Cambridge.

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    COMMENTS

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    justme
    7th Jun 2020
    11:38am
    It appears the YLC has begun to include ads with a Close X that are in fact links to a new page all about the advertised product.
    If a close sign can't be trusted on a website, what else can be trusted.
    Wouldn't buy from such an advertiser no matter how good a deal "offered".
    Trimcat
    7th Jun 2020
    12:00pm
    I agree. Extremely annoying!
    Teacher
    7th Jun 2020
    12:09pm
    I have had experience in listening to my body's feelings about taking blood pressure tablets. I had symptoms where I felt that my blood pressure was too low rather than too high. Yes, I was right. Doctor said it was too low and to discontinue taking the tablets.
    If I had not listened to my body I probably would have passed out at some time, maybe even when I was driving.
    Incognito
    7th Jun 2020
    12:21pm
    Yes only you know your own body, the doctors are only guessing. There are other ways to regulate your blood pressure naturally.
    Incognito
    7th Jun 2020
    12:20pm
    The best medicine is "preventative" medicine. Big pharma is only interested in profits not healing people, it will never change unless people start taking care of their own health and refuse to use these so called 'medicines' unless absolutely you have no other choice to keep you alive as in surgery or near death.
    JayUK
    7th Jun 2020
    3:59pm
    I was taking a pill every day for blood pressure but wondered whether I needed to take them as often as that so tried reducing to three a week and it still keeps my blood pressure at the same desired level.
    I was also taking statins every day but was getting the visual disturbances that you get with migraines. I googled to see whether anyone else had reported the same and sure enough several had. I'm now reducing those tablets to three a week too but I don't know yet how my cholesterol level has been affected but I'm no longer getting the visual problems.
    Julian
    8th Jun 2020
    10:26am
    Having worked in pharma, I can see both sides of the usual argument. Call it it an unnecessary evil but medicine has improved the quality of life for countless including you the readers. If you've never taken any medication of any sort them count yourself extremely lucky.

    To imply a class effect (noting the example given with SSRI's) is somewhat misleading. Formulated molecules directly target specific receptors to gain access to the cell. Not all drugs within the same class have the same effect which is why some will be better tolerated than others. A Dr will usually check your tolerance after a short period on a new medication. If there are side effects (and there usually are with all medications) or there is negligible effect, then an alternative may be considered. A classic example are anti-inflammatories and an effective but considered dangerous drug removed from circulation in 2004. Not all were tarred with the same brush due to either their pharmacological action or molecular structure.

    Whilst not defending the pharma industry, it is a business like any other. It employs people and it needs to turn a profit.
    Incognito
    8th Jun 2020
    1:02pm
    Health should not cost money, the trouble is that big pharma want to make too much money, they will not put out a relative cheaper drug over a more expensive one that does the same job. They push too much medication onto people who do not need it. My brother died from too many "medicines" doctors just kept giving him more and more until he died from complications of having too many, no guidance whatsoever, but you cannot hold the doctor to account, they are protected by big pharma and the "medical" system.
    The last time I got help from a doctor who prescribed me anti-biotics I got sicker, so I cured myself through my own research and trial and error, they should stick to surgery only, that is where I have respect for doctors when they put people back together after accidents etc.
    Maggie
    8th Jun 2020
    10:45pm
    What we need is a much greater emphasis on prevention.
    A huge proportion of all illnesses are caused by the consumption far far more sugar and salt than we need. Only governments can get this under control on any scale. It's quite clear that people just do not take responsibility for themselves.This is made difficult because labelling of ingredients is often deliberately confusing to consumers. We need a tax on sugar if that's the only thing which works.
    We need bulk in our diets from unrefined carbs and lots of vegetables. They are a weapon against bowel cancer and piles.
    We need smallish portions of real fats, read butter and olive oil.
    With a few simple changes we would maintain healthy weight, with a reduction in hypertension and diabetes, and wear and tear on our joints.
    Add exercise and we wouldn't need all the medicines we take.
    At the end of the day we are responsible for having to take them and their side effects not doctors and big pharma.
    Incognito
    8th Jun 2020
    10:54pm
    I agree with all you said except the fat's, we need very little fat's and there is evidence that animal fat contributes to heart disease etc, most people have too much because it is high in calories this can cause weight gain too. I think most people just have no idea how many calories they consume in a day, they just eat what they like and much of junk and packaged foods is designed to make you feel like you want to eat more than you need.
    Maggie
    8th Jun 2020
    11:10pm
    A LITTLE animal fat won't cause heart disease and it's not artery clogging like margarine and trans fats which do cause coronary artery disease.
    You are so right about food made more attractive by the addition of salt and sugar, and the fact that most people just eat what and when they like, even when they know about healthy eating too!
    The kids are all taught about it at school now.
    I know that sadly veg and fruit is expensive for people who don't have much money and it's got even more expensive recently.
    Incognito
    8th Jun 2020
    11:18pm
    I am on a very low income but have always managed to eat heaps of fruit and veggies, but I guess it is because I do not eat out, avoid expensive packaged foods, and do not eat animal proteins.Or buy the latest and greatest in everything rather I make do with what I have. Farmers markets are good for fresh fruit and veggies, and Woolies now have the odd bunch which is still all good food. If you eat everything that is in season it is not expensive. It never ceases to amaze me how people will complain about the price of food and then go out and eat or buy the latest phone and clothes, guess it is important for some to look good rather than feel healthy.
    If the Government was serious about helping people be healthy then maybe they need to fund some programs to educate people more via sugar tax or something.
    Maggie
    9th Jun 2020
    1:38pm
    Incognito if you can get to a farmer's market without a car and without public transport you are fortunate indeed.
    My experience of farmer's markets is that while they have beautiful veg it's usually more expensive than in the supermarkets.
    The low income people that I am thinking of don't even dream of new fancy clothing and technology. I am thinking of all the single mothers battling along just to pay for hot water and heating.
    Sure you can buy ((mainly large) packs of odd veg and make soup, but a lot of the time there are things like 5 avocados in one pack which all ripen at the same time.
    Incognito
    9th Jun 2020
    1:49pm
    .These days with home delivery you do not even need to go out, and we have many more charities giving out food than before. Avocados are always expensive compared to other fruits and veggies. I could write a book about being frugal but keeping healthy. And I still don't have heating on during the day, only wood fire at night. No air con in summer either. You just have to adjust your life and not try to live like other's do to make ends meet. But I must admit it is getting harder with prices of everything rising all the time especially rents, mine has gone up every year.
    Maggie
    9th Jun 2020
    2:44pm
    Wow! If you can think of having food delivered you are a lot better off than many. Woolworths charge $10 for orders under $100.
    Coles looks cheaper because if you live near enough you pay ,$4.00 however the further away you live the more expensive it gets. I had to research this because I couldn't afford to think about it!!!
    Most of us, especially those who had children to raise would be able to contribute many chapters to your book.
    I'm happy you manage so well. Even a fire at the end of the day is beyond some.
    Incognito
    9th Jun 2020
    3:02pm
    Using delivery service is about stocking up and making most of the delivery fee which can be cheaper than driving, for me it is anyway. The more you spend at Woolies the less you pay for delivery. Firewood is my biggest expense but still cheaper than electricity and I do collect my own kindling and other tree branches where I can to supplement, hard work but keeps me fit. Also I do not have a good electric heater in this old house. IGA can be good for home delivery too locally anyway. Might have to do that book one day when I have the time.
    Maggie
    9th Jun 2020
    5:49pm
    Incognito we could continue going back and forth on this subject but if you can speak of bulk buying and poverty in the same breath, you really do not have a clue.
    Real poverty is living literally from hand to mouth and there are plenty of people living like that right here in Australia right now. And you talk of having $100 or more to get reduced delivery fees. Don't make me laugh or more appropriately cry!
    You are lucky to be a able to afford your wood, and lucky to live in an area where there are bits to be collected.
    I hope nothing ever disturbs your little world. I genuinely mean that.
    I am now done with this correspondence.
    No doubt we will bump into each other again unless you change your name again and I miss you for a little while. Take care.
    Incognito
    9th Jun 2020
    5:54pm
    Real poverty does not exist in Australia, try Indonesia and India. We have enough to go around, I live below the poverty line like a lot of people but I was forced to learn to manage things, that is what needs to be taught to a lot of people who have no clue sadly. Till next time, eat well.
    Maggie
    10th Jun 2020
    1:13pm
    I am not done after all. Your head must be in the sand if you can say there is no poverty in Australia.
    Last year there was a documentary about the 160,000 homeless women in Australia, some reduced to living in cars if they were fortunate enough still to have one. Some of the less well off live on the streets.
    There have been documentaries about people waiting for the bins to come out of Woolworths, Coles, restaurants etc so they can rummage for bits to eat. And no they are not all drunks and druggies. They are not much better off than the street poor of 3rd world countries .
    There are children here who are given breakfast at school because without it they are too hungry to be able to learn. The govt provides some funding for this but too many teachers are putting their hands in their own pockets to feed them and to provide other essentials for school.
    There are parents going hungry so that their children can eat .....
    I could go on but I won't because it's all documented and available on the internet on reliable sites. And there are many good programmes on TV.
    I know you mean well - just back up your arguments with research
    I would urge you to do some research
    Incognito
    10th Jun 2020
    1:27pm
    I do know and keep updated about homelessness and realize a lot of people for some reason are not able to access welfare, I do watch a lot of documentaries (like the one showing on ABC at the moment). Yes we do have people living below the poverty line, my point is that the majority of people in Australia can access welfare and charities and get help not like in places where there is no welfare like India and Indonesia etc, I have seen the documentaries about kids on the streets, families living between train lines and other horrible existences. So my point is yes we do have poverty, I live below the poverty line like many others and we can do better for those who are less fortunate, but we don't have the same level of poverty as seen in other less developed countries. In USA you have people living in cars and many go to work each day but cannot afford housing, I don't want to see this happen in Australia, yes we have people living in cars etc but that is because there is less and less access to affordable accommodation, why we need more social housing to be built. So I don't totally disagree with you Maggie :)


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