UEMO position on Disease Mongering / Quaternary Prevention

08/02/2011 Policy2 2446 Views

Quaternary Prevention

Quaternary Prevention is defined in WONCA’s Dictionary as «action taken to identify patient at risk of overmedicalisation, to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable» (2). It can also be looked at as the «rehabilitation or restoration of functions in those patients suffering from serious disease complications to avoid severe incapacity» (3). In the following paper we refer to the WONCA definition of Quaternary Prevention.

Medical profession as a whole is guided by the “primum non nocere” principle uncertainty being a key characteristic of our speciality of General Practice/Family Medicine (GP/FM) (1). Given the burdens and pressures put on  General Practitioners/Family Physicians (GP/FP) to accomplish their professional tasks, cases occur which should trigger profound introspection about the possible results of applying recommended techniques or measures (either pharmaceuticals or others), in order to promote health or quality of life , or simply to cure patients.

General Practice/Family Medicine aims to deliver medical care that is scientifically acceptable, personally necessary and ethically justified and adjusted to the needs and values of the patient  to achieve maximum quality with minimum quantity of intervention (4,5,6,7). The emphasis of quaternary prevention is to prevent iatrogenic harms and  to increase quality of life (7) and so it must be clearly differentiated from “primordial prevention” which consists of the use of techniques to reduce the emergence of life styles that are known to increase the risk of chronic degenerative diseases, mostly the non communicable diseases.

There are medical and population-based (epidemiological and economic) reasons for this kind of thinking (3,4,5,6,8). Although GP/FP seek to exercise their professional skills in the light of the best scientific knowledge, using evidence based medicine, it is essential to fully understand the necessity of using judgment whenapplying the findings of randomised controlled trials to a single individual.  The exercise of the required judgment on the part of both patients and doctors could be greatly helped by tools that quantify individual benefits and risks when making particular treatment decisions” (9).

All GP/FM involves the management of uncertainty and the awareness that all interventions carry risk of harm as well as the possibility of benefits. (10).  These realities become even more ethically challenging when offering preventive care to those who are currently well and GP/FPs need to be aware that the techniques of “disease mongering” tend to create more harm than “health” (11).

Even though there can be pressure from the media for the immediate application of new techniques, doctors have a responsibility to ensure effectiveness and safety of the treatments given to individual patients. GP/FPs have a responsibility to avoid “excess medical interventionism” with too many unnecessary or unjustified medical acts (12) by detecting individuals at risk of overmedicalisation overdiagnosing and overprevention  and suggesting ethically acceptable alternatives” (10,11).

In fact medicine can be understood by the public as the art of avoiding suffering and this unrealistic expectation may lead to excessive screening and/or treatment in the absence of well documented evidence, so generating a disease obsessed population, that should, instead, be empowered through well designed information campaigns at both the population and individual level. GP/FPs are in the right position to advise patients concerning health care and health systems and so to enable patients and healthy people to make autonomous health decisions in those fields where no immediate measures are indicated (13). In fact, some pursue medicine as a business exploiting contemporary greed and fear: “the greed is for ever-greater longevity; the fear is that of dying. The irony and the tragedy is that the greed inflates the fear and poisons the present in the name of a better, or at least a longer, future.” (14), as recent papers debate for a variety of fields including the most recent vaccination against HPV infection (15), prostate screening (16) or use of new anti-hypertension medicines (17).

In the light of the above UEMO:

Firmly insists that GP/FP combat disease mongering, which in itself serves for nothing more than financial profits, while propagating fear and undermining the quality of life;

Urges GP/FP to include quaternary prevention, at individual and practice level;

Advises scientists/researchers to be aware of the possible disease mongering implications of their publications and urges European and national health authorities to address this very important problem, that consumes time and resources without proportionate health gain..

Urges European and national health authorities to support GP/FD in their daily fight against disease mongering, overmedicalisation, overdiagnosing and overprevention.

(1) – http://www.euract.org/pdf/European{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba}20definition{cabf78295431282ca1bec49ffbe2c87b89a1285ae102b2d0687184fc21af24ba}202005.pdf

(2) – http://www.ulb.ac.be/esp/mfsp/quat-en.html , (accessed the 1st of May 2009)

(3) – Mensah GA, Dietz WH, Harris VB, Henson R, Labarthe DR, Vinicor F, el al. Prevention and control of coronary heart disease and stroke: nomenclature for prevention approaches in public health: a statement for public health practice from the Centers for disease control and Prevention. Am J Prev Med 2005 Dec; 29 (5 Suppl 1):152–7.

(4) . Gérvas J. Moderación en la actividad médica preventiva e curativa: cuatro

ejemplos de necesidad de prevención cuaternaria en España. Gac Sanit 2006 Mar; 20 Supl 1: 127-34.

(5). Gervas J. Innovación tecnológica en medicina: una visión crítica. Rev Port Clin Geral 2006 Nov-Dez; 22 (6): 723-7.

(6). Gervas J, Pérez Fernández M. Genética y prevención cuaternaria. el ejemplo

de la hemocromatosis. Aten Primaria 2003 Jul 30; 32 (3): 158-62.

(7). Almeida LM. Da prevenção primordial à prevenção quaternária. Rev Port Saúde Publica 2005; 23 (1): 91-6.

(8) – Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ 2002 Apr 13; 324 (7342): 886-90.

(9) – Evidence-based medicine targets the individual patient, part 1: how clinicians can use study results to determine optimal individual care. Dirk Bassler, Jason W Busse, Paul J Karanicolas and Gordon H Guyatt. Evid. Based Med. 2008;13;101-102


— Working fields and prevention domains in general practice/family medicine (Draft version 0.6) http://docpatient.net/mj/prev.html.

(12) – Gervas J, Pérez Fernández M. Genética y prevención cuaternaria. el ejemplo de la hemocromatosis. Aten Primaria 2003 Jul 30; 32 (3): 158-62.

(13) – Gervas J. Innovación tecnológica en medicina: una visión crítica. Rev Port Clin Geral 2006 Nov-Dez; 22 (6): 723-7.

(14) – http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030146

(15) Kim JJ, Goldie SJ. Health and economic implications of HPV vaccination in the United Status. N Engl J Med 2008 Aug 21; 359 (8): 821-32.

(16) U.S Preventive Services Task Force. Screening for Prostate Cancer: U.S.  Preventive Service Task Force Recommendation Statement.Ann Intern Med 2008


(17) Yusuf S, Diener HC, Sacco RL, Cotton D, Ounpuu S, Lawton WA, et al. Telmisartan to prevent recurrent stroke and cardiovascular events. N Engl J Med 2008

sep 18; 359 (12): 1225-37. http://content. nejm.org/cgi/content/full/NEJMe0806806v

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