We appreciate Martins et al ’s effort to present an amendment to WONCA’s P4 (quaternary prevention) definition. However, there are some problems with their approach. First, we found it problematic to state that ‘demedicalisation is often not a science-based concept’. Dating back to the 1960s and 1970s (for example, Ivan Illich’s Medical Nemesis — 1974) there is an enormous amount of academic and scientific evidence on the political and social implication of medicalising human experience. Second, it is a mistake to assert that P4’s new definition is ‘more than demedicalisation’ since it diminishes the scope of P4 by getting rid of the scientific concept of medicalisation. Apart from individual clinical harms, there are social and cultural iatrogenies, which are characterised by humans’ impoverishment in dealing with life’s inherent crises. This generates excessive dependence on, and demands for, medical interventions for almost all human hindrances. Third, evidence-based medicine (EBM) is presented as the only valid paradigm. Unfortunately, EBM is not a neutral phenomenon, but a socially constructed approach to authority over medical knowledge.
There are vested interests in biomedical research, and its agenda is value laden. EBM deals, in general, with monodisease scenarios, excluding complex and multimorbid patients from clinical trials. In complex cases, the realm of P3 and P4 (as in medically unexplained symptoms), polypharmacy tends to be the norm. They need careful assessment by GPs. Fourth, the ‘new definition’ drops Jamoulle’s insight on the origin of P4. P4 was born by highlighting a particular group of patients: those who feel unwell, but have no disease, which includes mental health problems. The latter needs a new understanding that surpasses the EBM paradigm, but includes the philosophical, sociological, and anthropological perspectives. Finally, GPs have to expand what counts as medical interventions. Thus, Martins et al ’s proposal seems to portray that the ‘cure has been worse than the disease’! Not all GPs’ activities can be evaluated by ‘EBM paradigm’; in fact, most of them cannot. Therefore, WONCA’s P4 definition requires clinicians to reflect upon what sort of lens (the clinical gaze) they are using in order to constrain biomedical jurisdiction and to protect patients from being medicalised.
- © British Journal of General Practice 2020
