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Abstract

“Disease mongering” is a widening of the diagnostic boundaries of illness for reasons of economic beneﬁt. Employed by pharmaceutical companies, doctors, and others with similar interests, it is becoming a matter of great concern, particularly in developed economies: the USA, the EU, Australia, and Japan. It has developed as part of “medicalization,” the attempt to label ordinary human conditions such as birth and death as medical and transform them into the subject of medical intervention. Behind the problem of disease mongering lies a conﬂict between the market principle by which the pharmaceutical industry conducts its business and the altruism on which modern medical ethics is based. There should be an open discussion as to how such ethical conﬂicts may be solved.

Introduction

Frequently used in a pejorative sense, “disease mongering” connotes a widening of the diagnostic boundaries of illness (Payer 1992; Moynihan et al. 2002). It is most often employed by pharmaceutical companies, doctors, or others with similar interests, who conduct disease awareness campaigns on the pretext of educating the public about the prevention of illness or the promotion of health. Under the cover of early detection and early treatment, they strain the conceptual domain of diagnostic categories to their own advantage.

Encouraged by these disease awareness advertisements, the public gradually becomes concerned that they are ill and require medical treatment. As a result, pharmacotherapy is increasingly being applied to ever milder conditions, leading to potentially unnecessary medication, wasted resources, and even adverse side effects.

Proponents of this practice justify disease awareness campaigns, arguing that the pharmaceutical industry is simply providing the public with information about its options and that the option of receiving medication is a matter to be discussed between patient and doctor. Opponents claim that the true intent of disease awareness campaigns is primarily or even exclusively to produce proﬁt for the drug companies. Furthermore, opponents suggest that by inspiring fear of illness, these campaigns drive patients to demand potentially unnecessary prescriptions, which may have unfavorable consequences instead of beneﬁts.

Target Diseases

Clinical categories targeted in disease mongering have four points in common. The ﬁrst is that they lie in the boundary between the normal and the abnormal. For example, the medical model of mental illness can apply to some classes of psychiatric disorders, such as severe cases of schizophrenia or Alzheimer disease. However, even in such authentic psychiatric illnesses, determining the limits of the applicability of the medical model is arbitrary. Needless to say, such a difﬁculty is much greater with less clear psychiatric categories, such as bipolar disorder, social anxiety disorder, and ADHD. Likewise, physical illnesses such as reﬂux esophagitis, overactive bladder, and erectile dysfunction do exist. Yet the distinction between symptoms of these diseases and complaints within normal limits is vague. This opens up marketing opportunities. Success in extending diagnostic boundaries leads to great proﬁt. The wider the domain of disease, the larger the proﬁts.

Secondly, disease mongers target neither fatal nor short-duration diseases. In both cases, pharmacotherapy is a temporary need, and therefore, the span of proﬁt making is short. From a marketing point of view, it is ideal that patients do not die soon, do not recover soon, and continue the medication as long as possible, hopefully for life.

Thirdly, disease mongers target common rather than rare diseases. A condition uncommon for family doctors cannot create a plentiful source of proﬁts, due to limited opportunity for drug prescription.

Fourthly, to secure higher proﬁt, the drug should be administered for as long a period as possible. The longer the dosing period for a particular drug, the better. For example, for the treatment of gastric ulcers, gastric secretion inhibitors are much more proﬁtable for drug marketing than eradicating agents for Helicobacter pylori. The former brings the pharmaceutical companies proﬁt for months or years for each patient, the latter only for days or weeks.

Disease mongering can include many nonpsychiatric conditions such as male baldness, female sexual dysfunction, premenstrual dysphoric disorder, reﬂux esophagitis, overactive bladder, and erectile dysfunction. Even so, among all ﬁelds of clinical medicine, psychiatry is perhaps the most vulnerable to the dangers of disease mongering. The psychiatric conditions most commonly targeted by the pharmaceutical industry include social anxiety disorder, ADHD, bipolar disorder, and depression. All of these categories satisfy the four conditions suitable for disease mongering.

As a result of the attempts of disease mongers to encroach upon the sphere of normality, the global market for pharmaceuticals has shifted from drugs for life-threatening diseases to those for “lifestyle” or “risk management.” According to Healy (2012), the market scale of worldwide pharmaceuticals is US$900 billion. Yet most of the best sellers are “lifestyle” drugs: antidepressants and other psychotropic drugs ($60 billion), cholesterol-lowering statins ($34 billion), acid reﬂux drugs ($26 billion), blood-sugar-lowering drugs ($24 billion), and treatments for osteoporosis and sexual dysfunction.

The Term “Mongering”

Prior to the ﬁrst appearance of the coined expression “disease mongering,” the word “mongering” had been used with an uncomplimentary and critical connotation. Originally, the sufﬁx “-monger” denoted a retail commodity trader, such as a costermonger, ﬁshmonger, cheese monger, or ironmonger. However, words used out of context are in danger to gain negative connotation. In the case in point, “mongering” denotes a person who promotes an undesirable, contemptible, or discreditable activity: gossip monger, panic monger, scandal monger, rumor monger, etc. One example is the term “warmonger,” which is used to refer to a person who is eager to encourage nations to war with the hidden intent of proﬁt for the munitions industry.

Precursors To The Disease-Mongering Trend

Pharmaceutical industry now spends almost 25 % of its sales on promotion, nearly twice as much as it spends on research and development (Gagnon and Lexchin 2005). Although many suppose such exploitation campaigns to be a recent development, their direct ancestor already appeared in drug advertisements of the late nineteenth century. Henry James, the American novelist, was so irritated by this type of advertisement that he called the sellers of magic bullets “nostrum mongers” (Applebaum 2006). His brother, philosopher William James, was also annoyed by such marketing techniques and even referred to the authors of these advertisements as “public enemies” (Laird 1998).

Dossey (2010) pointed out that the Listerine mouthwash campaign was a precursor to the disease-mongering trend. In 1914, Listerine, originally used as a surgical antiseptic, became the ﬁrst over-the-counter mouthwash, distributed in the USA. To promote Listerine as a “cure,” its manufacturer, the Lambert Pharmacal Company, created a “disease” called “halitosis.” Although this novel “disease” had hitherto been unfamiliar to anybody, it grew at an epidemic rate all over America, thanks to the “halitosis” awareness campaign.

The sales trick of Listerine was to project the image of halitosis as a disastrous disease which could, with a single symptom, extinguish anyone’s opportunity of succeeding in love, marriage, or employment. In fact, bad breath was merely a common condition of no concern to anybody whether present or absent. The Listerine sales techniques, however, advanced this obscure jargon to a seat in the medical nomenclature. Since then, the strategy of the Listerine campaign has been taken over by other pharmaceutical companies, which are aggressively involved in fostering the concept of new diseases and imposing them on both doctors and consumers.

Medicalization

Before the concept of disease mongering developed, the term “medicalization” had entered the literature of sociology and medical anthropology in the 1960s and 1970s. Medicalization refers to the attempt to label ordinary human conditions and problems as medical and transform them into the subject of medical study, diagnosis, and treatment. While the term “disease mongering” has antiproﬁteering implications in terms of sales promotion by pharmaceutical companies, “medicalization” implies political criticism of social control through the power of medical authority. Authors committed to this argument are Ivan Illich, Franco Basaglia, R.D. Laing, Thomas Szasz, and Michel Foucault.

In 1975, Ivan Illich, an Austrian philosopher, published a book titled Limits to Medicine: Medical Nemesis (1975), in which he criticized the excessive medicalization of so many of life’s natural events such as birth and death. Introducing the concept of “iatrogenesis,” disease brought forth by the doctor, he pointed out the risk that medicalization could render even healthy people in effect lifelong patients. Causes of iatrogenesis include the varieties of unfavorable effects of medical intervention in a technically advanced society. According to Illich, iatrogenesis is categorized into three types: the clinical, represented by adverse side effects more serious than the primary condition; the social, in which the general public is so trusting that they rely on medical professionals to cope with their everyday problems; and the structural, in which natural human events like aging and dying are effectively controlled in a totally medical way and individuals in their society are thus no longer able to manage these “medical” phenomena on their own.

For many years psychiatry has given rise to much controversy, as it is claimed to engage in the systematic medicalization of normality. Under the conviction that mental illness is a consequence of exclusionary processes, Franco Basaglia and his followers considered psychiatry to be the provider of medicalization of deviant behavior. R.D. Laing, the most inﬂuential leader of the anti-psychiatry movement, wrote a best-selling book, The Divided Self, in 1960. He argued within that we could understand schizophrenia, viewing it as a transformative state involving a sane attempt to cope with an insane society. Thomas Szasz published The Myth of Mental Illness in 1961 (Szasz 1961). According to Szasz, the notion of “mental illness” was nothing but a contradictory and incoherent amalgamation of a medical, a psychological, and a social concept. He complained that psychiatry had the power to forcibly detain and treat people for mere deviance from social norms, despite a lack of sound scientiﬁc evidence of a disease. Michel Foucault, a philosopher, criticized the epistemological basis of psychiatric practice, which he viewed as an instrument of oppression. In his 1961 book Madness and Civilization: A History of Insanity in the Age of Reason (Foucault 1961), he examined the process through which people’s attitude toward those seen as “insane” had altered in accord with the historical transition of values in society. He argued that psychiatry had been abused as a social tool of restraint, deemed a “great conﬁnement” of the insane by social historians.

Until the late 1970s, sociologists, philosophers, and psychiatrists criticized medicalization in the name of liberation, based on the assumption that the power of the medical profession dominates individuals. Their targets included medical professionals with authoritarian attitudes, increasingly sophisticated technology, an oppressive capitalist society, and male chauvinism ruling over the predominantly male medical profession. Such questionable enemies have more recently been replaced by pharmaceutical industries as a target for critics of medicalization.

Disease Mongers By L. Payer

In 1992 the health science writer Lynn Payer introduced the term “disease mongering.” She published a book titled Disease-Mongers: How Doctors, Drug Companies, and Insurers Are Making You Feel Sick (Payer 1992). According to her, disease mongers are those “trying to convince essentially well people that they are sick, or slightly sick people that they are very ill.”

Payer listed several practices of disease mongers as follows:

Taking normal human experiences and indicating the possibility of something wrong with them in need of treatment
Identifying suffering that is not necessarily present
Deﬁning a “disease” such that a large proportion of the population suffer from it
Characterizing a condition as some indeﬁnite deﬁciency or chemical imbalance
Recruiting advisory doctors to associate a condition with an all-out disease awareness campaign
Using statistics arbitrarily to overstate treatment beneﬁts
Advertising a treatment beneﬁt, without reference to adverse effects
Raising alarm about a common symptom as if it served as a prelude to a serious disease

It is easy to attribute this shameful deception called disease mongering to people’s over anxiousness about disease and the commercialism of pharmaceutical companies. However, in Payer’s view, the real background is complicated, involving not only doctors and pharmaceutical companies but also lawyers and insurers. All groups in this situation are exposed to invisible, but immense, pressure to extend the diagnostic boundaries of treatable illnesses in the insured population. People are driven to a fear of illness. Naturally, they worry about trivial symptoms and ask doctors for medical tests, often little diagnostic value. Doctors are confronted with accusations of misdiagnosis and malpractice. In turn, for self-protection, they routinely urge people to undergo extensive medical examinations and expensive pharmacotherapy. Insurers, in their usual manner, will reimburse for tests and treatments. As a consequence, a series of incongruously sophisticated examinations and an accumulation of unnecessary medical interventions will be carried out. In this spiral of anxieties and interventions, both doctors and public forget to weigh the risk and beneﬁt of each test and treatment. Instead, they suffer from serious medical perfectionism: whatever is ailing you must be a sickness, and therefore, it must be treated. In prosperous years for doctors, insurers, and pharmaceutical companies, people do not recognize the risk of jeopardizing health.

Controversy Regarding Disease Mongers

Payer’s book gave rise to much controversy. However, even opponents admit that Payer’s discussion carries conviction in the contexts of pharmaceutical companies’ marketing strategies, the exaggerated exploitation of minor conditions as serious diseases, and the accelerated encouragement of unneeded corrective surgery.

Payer’s analysis of the abuses of disease concepts mainly targets modern American medicine. According to Roy Porter (1993), a British medical historian, the disease mongering Payer exposes can be characterized as typically American; it would never happen in the Old World. Yet the British government slowly nudges the British National Health System toward private medicine, where Payer’s cautionary advice will eventually be needed. Meanwhile, Porter expresses another concern that disease mongers themselves might also cause a further scare. Works like Payer’s book have the ironic potential for doom mongering effects of their own. To hedge the risk of “disease-monger mongering,” Porter considers two requirements. The ﬁrst is a radical deliverance of the American healthcare service from market-oriented principles. The second is a rethinking of public attitudes about health and life, from too much concern about health to more realistic resignation.

In his review of Disease-Mongers and related books, Dossey (2010) indicated two reasons for apprehension about disease mongering. The ﬁrst is the psychological burden in worrying about having a serious illness despite the absence of an actually serious medical condition. The second concern is about ﬁnancial costs. Indeed, treating these “diseases” with drugs costs a lot in money and in personnel. Furthermore, any healthcare system cannot bear the heavy economic burden of drug treatment for all possible risks that the drug companies induce the population to treat. Dossey recognizes difﬁculties in withstanding the trend of disease mongering. This is because powerful economic and professional interests lie in the process where huge advertising expenditures are invested in marketing drugs for dubious diseases. At the same time, he makes proposals for resisting the attempts of the disease mongers. He reminds us of the self-evident truth that our health is determined not exclusively by the pills we choose to take, but rather by how we choose to live our lives. He emphasizes that changing lifestyle habits like the ways we eat, exercise, work, and relate to others can be the best way to outsmart the devices of the disease mongers. In this respect, he agrees with Heath’s opinion (Moynihan et al. 2002) that what we need is to develop psychological and spiritual maturity. Heath realizes that the underlying cause of susceptibility to disease mongering is our fear of aging, suffering, and death in an era without religious comforts. Needless to say, neither better health nor longevity can be given by the panicky pursuit of any tablets pushed by disease mongers.

A 2006 International Conference On Disease Mongering In Newcastle, New South Wales

In 2006 the world’s ﬁrst international conference on disease mongering was held in Newcastle, Australia, and then reported in a special theme issue of PLoS Medicine (2006). It encompasses a total of 11 articles, moving from an introductory remark and a general overview to particular topics, such as pharmaceutical marketing, government, and medical and pharmaceutical students as well as case studies about erectile dysfunction, ADHD, female sexual dysfunction, bipolar disorder, restless legs syndrome, and Alzheimer disease.

The Doctor’s Role In Disease Mongering

The topic of disease mongering raises the question of a doctor’s autonomy. Formerly the doctor was regarded as an authoritative professional who actively promoted disease mongering in collusion with the pharmaceutical industry. Such a simplistic notion of the doctor’s role has recently been called into question. Indeed, a doctor retains the responsibility to prescribe drugs to patients or to refrain from doing so. However, the doctor is thoroughly indoctrinated in the marketing strategy of the pharmaceutical company (Kumar and Hedge 2006).

The doctor’s prescribing behavior is controlled through something closely akin to Pavlovian conditioning, by providing “drug information,” actually biased to the proﬁt of the pharmaceutical industry. This includes frequent visits by medical representatives, the never-ending provision of “current information,” training courses for the diagnosis of “unrecognized diseases,” invitations to conferences for the treatment of “unmet needs,” and incentives for attending such meetings, such as lunch and gifts. Like a dog salivating in response to a bell associated with food, the doctor becomes inclined to automatically prescribe the drug recommended by the company.

Another reason for the loss of the doctor’s autonomy is the fact that the pressure for prescription comes from patients themselves, not from salespeople. The attitude of the patients has changed. They are no longer pitiful victims only passively receiving medication. On the contrary, they can now be in the driver’s seat to make a decision as consumers or advocates. For example, in the USA, where direct-to-consumer advertising is legally approved, patients are induced to ask doctors for speciﬁc drugs they want. In theory doctors should be authority ﬁgures primarily responsible for prescription. However, they are wallﬂowers in the intimate discussion between consumer and drug company with regard to the decision of medication.

The Responsibility Of The Media For Disease Mongering

Although the argument about disease mongering tends toward an indictment of pharmaceutical companies and medical professionals, the role of media is also a matter of vital importance (Woloshin and Schwartz 2006).

Since the rhetoric about new disease is so sophisticated, even the most skeptical journalists cannot always spot the hidden intentions of disease mongering from the pharmaceutical company, allied experts, and advocacy groups. The disease targeted by disease mongers is typically located on the spectrum between normality and abnormality. The degree of severity extends from the minimum unpleasantness nobody would describe as “symptoms,” on the one hand, to the most serious suffering everybody would recognize as “pathologic” on the other. The disease marketers covertly contrive to narrow the domain of health and enlarge that of disease. Trivial complaints are interpreted as precursory symptoms of terrible malady and mere risk factors are identiﬁed as real disease. Dramatic stories are presented, as if there were a disastrous public health problem, patients left in a sorry plight, doctors incompetent due to ignorance, and magic bullets possibly relieving the unfortunate sick.

Indeed, the journalism should, on behalf of the public, act as a kind of watchdog against authority, including the pharmaceutical industry. As a guardian of the citizens, the role of a watchdog journalist is to provide them with valuable information necessary for the prevention of any abuse of power. Journalists should thus keep a certain distance from the pharmaceutical companies. Nevertheless, the sophisticated control of medical information by the pharmaceutical industry bamboozles journalists into joining the drug promotion. Being loyal to the ruling power of the big industry, they may wind up as “propagandist” journalists, the exact inverse of a watchdog.

To illuminate the involvement of the media in the disease awareness campaign for drug promotion, Woloshin and Schwartz examined news coverage of “restless legs syndrome” (RLS). RLS is diagnosed when the following four symptoms are present: an urge to move the legs due to an unpleasant feeling; onset or worsening of symptoms when at rest or not moving around frequently; partial or complete relief by movement (e.g., walking) for as long as the movement continues; and symptoms that occur primarily at night and that can interfere with sleep or rest. Woloshin and Schwartz (2006) analyzed 33 newspaper articles in terms of the three key elements of disease mongering: exaggerating the prevalence of the disease (e.g., uncritically accepting a broad prevalence estimate), encouraging more diagnosis (e.g., doctors fail to recognize it), and suggesting that all cases should be treated (e.g., overstating the beneﬁts or minimizing the adverse effects of treatment). Almost two-thirds of the articles provided an estimate of RLS prevalence such as one in ten adults in the USA. Yet no article questioned the validity of the estimate. Although about half thought RLS to be underdiagnosed by doctors and underrecognized by patients, no article addressed the possibility of overdiagnosis. About half the articles mentioned the drug Ropinirole by name, including anecdotes about patients who took the drug. However, no news story pointed out that the actual beneﬁt of the drug is modest. Moreover, only 5 of the 15 articles noted that Ropinirole could have side effects.

Woloshin and Schwartz concluded that journalists should be skeptical of information about disease and drugs in the following three ways. First, when faced with a new disease affecting a large number of patients, prevalence estimates may be exaggerated. Second, despite indications of underdiagnosis and underrecognition, more diagnosis and more treatment may not always be a good thing. Third, instead of being dazzled by dramatic anecdotes about miracle cures, journalists should give accurate information in terms of how the treatment acts, hopefully with quantiﬁcation.

The Fundamental Nature Of The Pharmaceutical Industry

To have a proper understanding of contemporary drug marketing, it is essential to recognize the pharmaceutical industry for what it is. The business activities of pharmaceutical corporations do not aim at the beneﬁt of individual patients, but at proﬁts gained from the drug market. Pharmaceutical companies are by deﬁnition limited corporations formed for the purpose of engaging in business. They have, without exception, a lawfully guaranteed right to maintain economic activities for money-making purposes. They behave in accordance with economic principles, which stand in sharp contrast to the ideal principles of medical ethics that trace back to doctors’ codes in antiquity, such as the Hippocratic Oath. Pharmaceutical corporations are homo economicus, i.e., rational and narrowly self-interested actors who can give decisions with their own aim of making proﬁts. According to their rational judgment, they pursue their business to maximize economic proﬁt as producers. They are primarily motivated by the desire for their own advantage, regardless of others. Their behavioral principles are alien to the altruism of modern medical ethics which considers the unselﬁsh concern for the welfare of others as inherent in the medical profession.

Pharmaceutical companies attempt to commercialize new drugs for ﬁnancial proﬁt. Here, commercialization refers to the introduction of goods into the general market. In their earliest period new compounds developed in the laboratory are not appropriate for commercial adoption. In order to make a drug a paying commercial proposition, the process of commercialization must include the question of whom to target. Understanding consumer behavior and choosing the new drug’s target customers is referred to as marketing. From a societal point of view, marketing is the practice of linking between the value of a drug and the needs of consumers. Thus, the relationship pharmaceutical marketing aims at is not a patient-doctor relationship, but a customer-supplier relationship.

According to Applebaum (2006), at the core of marketing theory, there is an assumption of insatiable needs and wants. In his opinion, marketing can be understood as the activity of institutionalizing this view of human nature. Naturally, each marketer makes every effort to convert those boundless needs into unlimited proﬁt. Exposed to a continuous ﬂow of advertisements, people are conditioned to want more and more. These advertisements make them feel like resolving their personal anxieties and dissatisfactions through ceaseless consumption. The same suggestion is offered by pharmaceutical companies through advertisements for new drugs.

In spite of the fact that the primary purpose of drug marketing is self-interest, the pharmaceutical companies can justify their activities by capitalizing on people’s fear of illness. The drug industry arranges a fusion of their proﬁt-seeking scheme, whereby people’s anxiety about disease is taken as a business opportunity, to the appealing pretext that remedy should be given to the sufferers.

Although business organizations in theory are allowed some degree of discretion in market economy, they are compelled to balance their activities for proﬁt with societal beneﬁts. For the pharmaceutical industry, ethical justiﬁcation for drug marketing is essential to meet with general acceptance. Drug marketers hence ally themselves not only to doctors and academic leaders but also to patients and patient advocacy groups. Once consumers are incorporated into the drug business, marketers are no longer hesitant to promote their products. They consider their practice to be for the welfare of the people rather than exclusively for the proﬁt of the industry. They can claim that all they are doing is providing people with autonomy in terms of treatment options. Here, the pharmaceutical industry succeeds in its efforts to link its commercial motives to ostensible public beneﬁt.

However, such power of self-determination makes no sense unless people are fully informed about their treatment options and understand the potential beneﬁts and risks. Due to the provision of somewhat biased information advantageous to the drug industry, people are liable to make poor choices. Under the proclamation that individual autonomy should be respected, people are at risk of receiving potentially unnecessary and indeed harmful treatment.

Disease Mongering Outside Western Countries

While the problem of disease mongering has been discussed widely in the international sphere, there has been a relative paucity of reports concerning the current state of disease mongering outside the USA, Australia, and the EU, due perhaps to a language barrier. Ihara (2012) discussed disease mongering in the Japanese context, with a particular focus on depression.

In Japan, depression provides the most drastic example of the impact of disease awareness campaigns. Until the late 1990s, the public’s attitude toward depression was generally unfavorable, due to the negative connotations of the Japanese word for clinical depression, “utsubyou.” After the 1999 introduction of the ﬁrst selective serotonin reuptake inhibitor, pharmaceutical companies initiated an educational campaign. In order to aid the drug’s acceptance, they coined the catchphrase “kokoro no kaze,” which literally means “a cold of the soul.” Thanks to these marketing practices, antidepressant sales have soared, from ¥14.5 billion in 1998 to ¥87 billion in 2006.

However, the catchphrase “kokoro no kaze” masked a critical difference between colds and depression. It falsiﬁed the nature of treatment for depression by concealing the duration of medication. Due to this distortion of information, pharmaceutical companies were assured a steady stream of proﬁts.

These depression awareness campaigns have been based on the syllogism: “Your depression may be a disease. It can be cured by antidepressants. Therefore, your depression should be cured by antidepressants.” This psychopharmacological reasoning is, even if valid, applicable only to the biological aspects of depression.

Ihara argues that the aggressive marketing of SSRIs inevitably produces a mismatch between what psychiatrists are trained for and what they are required to do. Due to the inﬂuence of the “kokoro no kaze” campaign, patients frequently underestimate the complexity of depression, believing that depression can be compared to the common cold and antidepressants to aspirin. On the contrary, chemical substances like antidepressants have limited powers and cannot solve all problems, especially psychosocial ones.

At this point, it is clear that the marketing of antidepressants has gone off course and that treatment for depression associated with psychosocial problems is beyond the scope of SSRIs. Nevertheless, the pharmaceutical industry has repeatedly infused people with one simple message: what is ailing you might be a sickness, and if so, it should respond to pharmacological treatment. As a consequence, the public tends to assume that SSRIs will allow them to overcome all life’s adversities. Due to these unreasonably heightened expectations, patients have also come to idealize psychiatrists, crediting them with the ability to solve problems that are social in nature. In reality, psychiatrists cannot deal with all problems, especially nonmedical ones. Unfortunately, this divergence between what patients expect of their psychiatrists and what psychiatrists can do often leads to disappointment. As a result, many patients may become angry with their doctors, even though the cause of this anger is simply a mutual misunderstanding between the two parties.

Disease Mongering From The Viewpoint Of Medical Ethics

Beauchamp and Childress (1989) postulated a “four-principle” approach to the analysis of values and judgments in medical practice in their textbook Principles of Biomedical Ethics. The four principles they formulate are:

Respect for autonomy – an individual has the right to make his or her own choice in terms of the options of treatment.
Beneﬁcence – a doctor or other medical professional has the duty to act in the best interest of others.
Non-maleﬁcence – a doctor or other medical professional has the duty to adhere to the principle, “above all, do not harm.”
Justice – a moral obligation to act on the basis of fair judgment between competing claims, emphasizing fairness and equality among individuals.

From the viewpoint of the “four-principle” analysis of medical ethics, disease mongering causes two problems. The ﬁrst is conﬂicts between autonomy and beneﬁcence/non-maleﬁcence, and the second is an unfair distribution of scarce medical resources contrary to the justice principle.

First, when patients’ preferred treatment options are not in their best interest, the principles of autonomy and beneﬁcence/non-maleﬁcence cannot help contradicting each other. In theory mentally competent patients have a right to make their own decisions, including even a right to do what is wrong. Medical professionals defer to their wishes, even in cases where the professionals believe that the patients are making an unwise choice. However, in some cases, beneﬁcence/ non-maleﬁcence should be given priority over autonomy.

For example, a patient may feel an obsessive fear of illness driven by disease mongering and in result may crave exhaustive examinations and invasive treatments, which in fact medical professionals take to be unreasonable. Indeed, medical professionals are required prudently to balance between the wishes of the patient and the potential risks of medically nonessential interventions. In the case where the potential risks exceed the beneﬁts from the patient’s satisfaction with the treatment, enough information should be provided to prevent excessive interventions from doing more harm than good. Yet, disease mongering exacerbates an individual’s susceptibility to hypochondria. Patients are thus too eager for medical treatments to comprehend the signiﬁcance of what will happen to their bodies. From a doctor’s point of view, the doctor-patient relationship should be maintained by satisfying the patient’s wants. As a result, in the name of respect for autonomy, the principle of beneﬁcence is jeopardized. At worst, out of a disinterested desire to respect the patient’s want and ease her suffering, maleﬁcent effects more serious than the primary condition can occur.

Second, since healthcare is a scarce commodity in an absolute sense, the ethical principle of distributive justice is of signiﬁcant importance. If healthcare had unlimited resources which could be efﬁciently produced and whose amount could thereby be augmented, it could be allocated according to willingness to pay. In reality, healthcare service is so scarce that an unlimited public provision cannot be guaranteed. Even if the demand side sent alarms of supply insufﬁciency, producers in healthcare could neither increase production in case of need nor remove any resulting scarcity thereby. Hence, the allocation of healthcare creates an ethical question.

However, the targets of disease mongering are exclusively “lifestyle” or “risk management,” in inverse relation to life-threatening diseases. An example is erectile dysfunction (ED). Lexchin (2006) shows how Viagra, a drug for ED due to medical problems, such as diabetes and spinal cord damage, was converted into a consumer product that “normal” men can use to enhance their sexual ability. Since the potential market in what until recently had been seen as the natural consequences of aging is huge, Pﬁzer, the manufacturer of the drug, targeted that much larger community. It organized an all-out campaign to raise awareness of the problem of ED, focusing on medication with Viagra as if it were the only treatment option. At the same time, however, Pﬁzer was presented with the refusal of insurers such as Kaiser Permanente to cover Viagra because of expanded costs.

Perhaps there must be an open debate as to how resources in short supply should be allocated. Since the healthcare system is a collectively ﬁnanced service, transparent rules should be applied to lifestyle drugs, such as Viagra. In Breyer’s opinion (Breyer 2009), a liberal society cannot avoid a two-tiered system of medicine: basic services for all, supplementary services for those who are willing to pay for them. Every citizen should accordingly participate in deciding which supplementary services to demand. Now is the time to begin discussing how we will prioritize drugs and other procedures that enhance lifestyle and drugs and treatments for far more serious diseases like cancer and AIDS.

Conclusion

Behind the problem of disease mongering lies a conﬂict between the market principle by which the pharmaceutical industry conducts its business and the altruism on which modern medical ethics is based. The former emphasizes not altruism but self-interest as a motivating force for social beneﬁt. In addition, even when altruism-based medical ethics are emphasized, there are mutual conﬂicts, as with the one between autonomy and beneﬁcence/non-maleﬁcence. There should be an open discussion as to how such ethical conﬂicts may be solved.

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