Originally, medicine was intended primarily to “cure” illness. Later, preventive medicine, as advice to patients about healthy living, also became part of physicians’ purview, informally at first and later institutionalised (Pickstone 2009).

At the other end was the support extended, mostly as charity, to older people suffering from diseases of old age, the bedridden and the chronically ill who need long-term care. This broadly falls under palliative care (Quest et al. 2009). Medical care has expanded beyond its traditional “curative care” in both directions: to screening, prevention and health promotion on one side, and palliative care and end-of-life support on the other, and to cosmetic surgery and wellness clinics.

Medicine and medical knowledge acquire the power to define what is right and wrong about body, life and death. As a social institution, medicine acquired control over people’s lives, entering every aspect of life by defining categories of normal and abnormal as central to every discourse and deeming that all forms of abnormality be attended by a qualified medical practitioner (Zola 1972).

In older times, medicine was reflexive of its limits and more focussed on curing illness. Doctors sometimes told patients that no treatment was needed for their complaint and that the illness would subside on its own after a few days of rest. In serious illness, families were told there was nothing more medicine could offer and that they might take the patient home to have a peaceful death. Neither possibility remains in medical practice, for reasons that are societal and institutionally binding.

The consumer patient

When the boundaries of medical care expanded, the power relations within hospitals and doctor-patient interaction also changed. More than the doctor, hospitals dictated procedures, and the do’s and don’ts of medical practice were laid out as standard operating guidelines. Physicians’ dominance in decision-making was questioned. Focus shifted to making the patient more powerful through shared decision-making, for which some transfer of power to the consumer was inevitable (Frosch and Kaplan 1999).

Once cure ceased to be an end point, care was substituted as the product medicine offered, and “patient satisfaction” became the new goal. Applying the Consumer Protection Act to medical care transferred a virtual sense of power to the patient as consumer, with a legal power to question the process of care. This added a consumer angle to the patient, which fuelled the existing commercial nature of medical care and gave it societal legitimacy.

Cure-oriented medical care is now evaluated on the care rendered to the patient, so patient satisfaction acquires prominence over clinical outcomes and all quality parameters revolve around it. This was the starting point of medical care’s commodification following market principles (Singh 1995; Bhat 1996).

The “consumer” patient began showing consumerism in medical care, which has expanded beyond diseases and is willing to take on anything society would consider under health, wellness and pleasure. Hospitals began repositioning themselves, responding to these needs and finding ways to generate revenue in every possible transaction. When medicine expanded beyond cure, patients began demanding services that may not fall within the purview of medical care. Self-limiting illnesses may not need intervention and would earlier have been dismissed as such. Patients have several kinds of fear, which a physician can dismiss when there is no supporting indication.

Medicalisation and risk

A range of life events in society gets articulated in the language of medicine and medical categories, prominent among them being the language of risk. Everybody can be at risk of one disease or another at any time and, as long as human beings are mortal, of death. Risk is nothing but a probability of an incident, but nowadays it is used mostly for a negative one, a disease or any danger (Fox 1999). The language of risk is legitimised as a technical language by medical knowledge.

Medical care responds to this concern by alleviating risk perception through screening, cosmetic services that increase confidence, painless deliveries, which women prefer as less risky, and several others.

This has created two aspects of life. First, for every other problem of humankind, medicine is expected to come out with a solution. Second, life is understood as a trivial condition: any life event can be risky and life-threatening, so one needs to be cautious every time. Zola (1972) portrayed this in a one-liner: “Living is injurious to Health.” This aggravates the mortal fear inherent in every individual, for which medical care is seen as a saviour.

This has led to greater power being attributed to medicine and medical care in every walk of life, known as the medicalisation of society. Medicalisation is a process by which categories of health, illness and healing become more important in daily life. It is not a natural event but is embedded in the way society engages with medicine (Zola 1972).

The engagement between medicine and society has to be understood in the context of the evolution of biomedicine, a practising profession that has stood the test of time because of its capacity to cure a range of illnesses. Medicalisation has to be understood as a “natural” consequence of the growth of a profession that traversed historic times and established itself as “scientific”.

Care as business

Medical care, on the other hand, is the way medicine was organised to make it available to people by making it simple and acceptable. Organising medical care has been a rational process of ensuring services to the needy according to the patients’ convenience. Because of the vested interests and the commercial opportunity inherent in every aspect of it, this has transformed medical practice into a business worth investing in.

One of the drivers of the commercialisation of medical care is the market, which constantly widens its boundary to accommodate more procedures. This generates demand for procedures that otherwise lie on the periphery of curative care, such as diagnostics and types of drugs used not always for therapy but also for assuring health and wellness. The newer players are technology, both medical and information, and insurance companies with their administrative machinery, such as third-party administrators.

This ability of medicine to transform the market, and the rise of commercialisation in every aspect of medical care, is what Relman (1980) identified in the US context as the medical-industrial complex, cautioning against it and comparing it to the military-industrial complex. When medicine expands its boundary, the core purpose of offering cure may become secondary and the primary purpose of organising medical care may be profit-making.

Risk in context

The expansion of medical care, increasing consumerism, rising risk perception and medicalisation are not isolated events but outcomes of the increasing complexity of life and of society. The anxiety created by complex life processes is translated into risk perception about susceptibility to disease, a common feature of any society.

According to Ulrich Beck (1992), risk is the probability of danger when things are normal. Risk is more of a perception, virtual in nature, than something that exists in reality. What exists is either being normal or being in a state of danger. In either case, risk does not exist. In health, when a person is healthy and normal there is no risk, and when a person is diseased they are already in danger, so there is no risk of disease but there can be risk of death. Risk of death is inevitable, so it is the risk of disease that is the most fearful situation in the context of medicalisation and medical care.

Risk of disease appears as a possibility for every individual, but at the population level there is a pattern that is mostly stable, and susceptibility to disease depends on people’s social context. It is incorrect to believe that anyone can get a disease at any time. This is borne out by the finding that age is still the most important risk factor for chronic diseases like diabetes, hypertension and cardiovascular diseases across populations (Merlo et al. 2017). Similarly, population-based information exists on the rate of hospitalisation, the proportion of minor illness and injury.

One of the drivers of the commercialisation of medical care is the market, which constantly widens its boundary to accommodate more procedures. This generates demand for procedures that otherwise lie on the periphery of curative care, such as diagnostics and types of drugs used not always for therapy but also for assuring health and wellness. Photograph used for representational purpose.
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BY SPECIAL ARRANGEMENT

There is a need to rationalise risk perception using population-based data, which can alleviate unnecessary fear to some extent. The medical fraternity’s role in this initiative is central, with hospitals playing an important part as a social institution.

Build trust through doctoring

Medical care now includes, through its expansion, the support services necessary for the practice of medicine through “doctoring”. Doctoring includes diagnosis, prognosis, and treatment, for which the major support services are diagnostic investigations and pharmacy, in addition to others. Diagnostic investigations and pharmacy have expanded and are becoming independent entities. The nature of doctoring needs to be examined and interpreted in this context, along with the factors that have contributed to the erosion of trust between doctor and patient.

Doctoring is a process by which an expert (doctor), by virtue of their knowledge, interprets the patient’s bodily distress (illness) and arrives at a medical diagnosis, for which solutions (treatment) are offered and at times performed (McKinlay and Marceau 2002). The uniqueness of medical care compared with other fields is that only the expert can know what is best for the patient, based on the information the patient offers (including subjecting the patient’s body to deeper analysis).

For a non-expert patient, every illness can trigger risk perception leading to fear of death, and can be worrisome until an expert offers a final diagnosis and prognosis. It is the doctor’s professional expertise and capacity to deal with life-and-death situations that provide doctors with prestige in every society. It is through this prestige that patients’ trust is created and sustained.

This calls for an altruistic relation between patient and doctor. This is possible only when medical care is rendered as a public good (McDermott 1978; Mariner 1995). Doctors can then be compensated only through regular salaries for the hours they work. Specialists and super-specialists can be paid higher salaries than generalists.

By contrast, when it is seen as a private good, doctoring and its compensation are no longer for a population but for each individual, according to the patient’s purchasing power. The doctor’s fees become specific to individual patients and the kind of illness rather than to the time devoted. Why are other professions engaged in medical care not compensated on the number of patients they serve or the nature of illness they treat?

Once the patient becomes the purchaser of care, the consumer within the patient is evoked and starts demanding value for money, as with other commodities, even when it is not medically warranted. Moral hazard in health insurance and women’s demand for caesarean deliveries are examples. There is a failure to acknowledge this uniqueness (Peppin 1999). Medical care has to be offered only when there is a “need” for it and not just because people “want” it.

Regulation of medical practice

There is a need to reinstate trust between doctor and patient. This is possible if, as a principle, every hospital takes a strict initiative to dissociate any possibility of accumulating wealth from medical practice. This means that, irrespective of whether a doctor treats 5 or 10 patients in a day, the severity of the illness, or whether the doctor prescribes a lab test, an X-ray, an MRI or a CT scan, doctors will earn the same. Medicine needs to be valued for professional service alone.

Whether the doctor is a generalist, a specialist, a super-specialist or a surgeon, salaries at every level need to be fixed commensurate with the time each cadre devotes to patients at the organisation. No hospital can pay doctors according to the number of patients they consult or treat.

This implies that a practising doctor has no opportunity to change their practice to generate revenue. A doctor’s practice is what medical science prescribes for a patient’s health condition, based on the latest standard guideline. The time doctors spend on each procedure becomes the basis for remuneration. If implemented, this becomes the most powerful form of regulation in medical practice and can build trust between doctors and patients.

Mathew George is a professor at the Department of Public Health Sciences, Central University of Kerala, Kasaragod.

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