Life & Times Quaternary prevention: a balanced approach to demedicalisation In 1982, the Journal of the Royal College of General Practitioners published Ivan Illich’s “The main problem of overdiagnosis is overtreatment: article ‘Medicalization in Primary Care’.1 Illich held a paradoxical belief that GPs treating pseudo-diseases that bear no prospect of could contribute to the healthy process of benefit.” demedicalisation, that is: ‘... to offer their patients the occasion to patients end up dying from competing 10 years.7 This increases the overdiagnosis de-medicalize their own attitude to pain, diseases and not gaining in longevity. effect and offers minimal individual benefit. disability, discomfort, ageing, birth and The main problem of overdiagnosis is Regarding P2, there are lots of instances 1 death.’ overtreatment: treating pseudo-diseases of overmedicalisation due to non-evidence- that bear no prospect of benefit.6 This based screening for thyroid, prostate, and In other words, ‘unhooking [patients] represents harm both to individuals’ ovarian cancers. Breast cancer screening 1 from the health system’. This article wellbeing and to health systems as also needs to be readdressed. After an presents WONCA’s definition of Quaternary it generates unnecessary costs and average of two decades of breast cancer Prevention (P4) as a unifying framework that waste of resources. Potential sources screening in Canada8 and the US,9 there 2 organises GPs’ scope on demedicalisation. of overdiagnosis are disease screening, are considerable overdiagnosis rates altering cut-off points for defining a risk (roughly 30%), minimal (if any) impacts on EXPLAINING QUATERNARY PREVENTION factor or a disease, and financial incentives mortality,10 but known potential harms such Devised in 1986 by Marc Jamoulle, a (for example, pay-for-performance as an increase in heart disease (27%) and Belgian GP, P4 is: schemes).5 lung cancer (78%) mortality.11 Concerning P3, diabetes care provides a ‘... an action taken to identify a patient at FIRST DO NO HARM good example. The belief in ‘the lower the risk of over-medicalization, to protect him An example of controversial P1 is better’ Hb1Ac levels has potentially done from new medical invasion, and to suggest prescription of statins for individuals more harm than good due to polypharmacy, to him interventions which are ethically reduction in quality of life, and an increase in acceptable.’ 3 with 10% cardiovascular mortality risk in P4 was initially oriented to those patients who were feeling ill, but who Box 1. Quaternary prevention framework as an organising principle for had no clinically established disease: the demedicalisation worried well and those presenting with Clinicians’ perspective (biomedical gaze) medically unexplained symptoms.3 The No disease Disease Demedicalisation former are concerned about their health P1 P2 P1 and P2 originally belong status and usually demand check-ups; the to public health tradition, as An action taken to avoid or An action taken to detect a latter present with symptoms that lack they deal with population remove the cause of a health health problem at an early pathophysiological explanations. Some of outcomes. Patients need problem in an individual or stage in an individual or these symptoms stem from psychosocial to be informed about population before it arises. population, thereby facilitating Feeling potential harms of each circumstances. Both groups of patients are It includes health promotion its cure, reducing or 4 well specific intervention due subjected to overmedicalisation. and specific protections (for preventing its spreading, to overdiagnosis and Box 1 provides a framework that organises example, immunisation) and/or long-term effects (for overtreatment the scope of P4. Its clockwise-arrow at the example, screening and early centre indicates that P4 impacts the other diagnosis) three preventive levels: primary prevention Patients’ (P1), secondary prevention (P2), and tertiary perspective P4 P3 P3 and P4 are the realm of prevention (P3). Box 1 also differentiates two personalised clinical care. An action taken to An action taken demedicalisation scenarios: 1) P1 and P2, Clinicians’ art of relieving identify a patient or population to reduce the chronic effect which deals with symptomless individuals; patients’ suffering and/or at risk of overmedicalisation, of a health problem in an and 2) P3 and P4, which comprises disease/ reassuring their wellbeing to protect them from invasive individual or population by illness dimensions, merging clinical care Feeling medical interventions, and to minimising the functional with preventive activities. ill suggest interventions that are impairment of an acute or Individuals undergoing P1 and P2 ethically acceptable chronic health problem might be subjected to overdiagnosis and (for example, prevent the overtreatment (that is, overmedicalisation). consequences of diabetes), Overdiagnosis is ‘the diagnosis of a condition including rehabilitation that would have remained indolent in the patient’s lifetime if left undetected’.5 Thus, 28 British Journal of General Practice, January 2019 12 Armando Henrique Norman, mortality. Therefore, distinction between ADDRESS FOR CORRESPONDENCE clinical and preventive activities is essential Lecturer, Department of Internal Medicine, Federal University of Santa Catarina, Santa Catarina, Brazil. Armando H Norman to circumvent the excesses of biomedicine. Department of Internal Medicine, Federal University In prevention, the bioethical principle of of Santa Catarina; Campus Reitor João David non-maleficence should prevail as we Charles Dalcanale Tesser, Ferreira Lima, s/n —Trindade, Florianópolis — SC, Professor, Department of Public Health, Federal are dealing with healthy or asymptomatic 88040-900, Brazil. University of Santa Catarina, Santa Catarina, Brazil. Email: [email protected] people, and the oath First Do No Harm should guide GPs’ practice.13 P4 implies DOI: https://doi.org/10.3399/bjgp19X700517 an attitudinal shift of self-containment, caution, and reassurance of patients’ integrity when dealing with preventive REFERENCES 7. Redberg RF, Katz MH. 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