Numerous criticisms of medical science have been articulated in recent years. Some critics argue that spurious disease categories are being invented, and existing disease categories expanded, for the aim of profit. Others say that the benefits of most new drugs are minimal and typically exaggerated by clinical research, and that the harms of these drugs are extensive and typically underestimated by clinical research. Still others point to problems with the research methods themselves, arguing that those once seen as gold standards in clinical research – randomised trials and meta-analyses – are in fact malleable and have been bent to serve the interests of industry rather than patients. Here is how the chief editor of The Lancet medical journal summarised these criticisms in 2015:
Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.
These problems arise because of a few structural features of medicine. A prominent one is the profit incentive. The pharmaceutical industry is extremely profitable, and the fantastic financial gains to be made from selling drugs create incentives to engage in some of the practices above. Another prominent feature of medicine is the hope and the expectation of patients that medicine can help them, coupled with the training of physicians to actively intervene, by screening, prescribing, referring or cutting. Another feature is the wildly complex causal basis of many diseases, which hampers the effectiveness of interventions on those diseases – taking antibiotics for a simple bacterial infection is one thing, but taking antidepressants for depression is entirely different. In my book Medical Nihilism (2018), I brought all these arguments together to conclude that the present state of medicine is indeed in disrepair.
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How should medicine face these problems? I coined the term ‘gentle medicine’ to describe a number of changes that medicine could enact, with the hope that they would go some way to mitigating those problems. Some aspects of gentle medicine could involve small modifications to routine practice and present policy, while others could be more revisionary.
Let’s start with clinical practice. Physicians could be less interventionist than they currently are. Of course, many physicians and surgeons are already conservative in their therapeutic approach, and my suggestion is that such therapeutic conservatism ought to be more widespread. Similarly, the hopes and expectations of patients should be carefully managed, just as the Canadian physician William Osler (1849-1919) counselled: ‘One of the first duties of the physician is to educate the masses not to take medicine.’ Treatment should, generally, be less aggressive, and more gentle, when feasible.
Another aspect of gentle medicine is how the medical research agenda is determined. Most research resources in medicine belong to industry, and its profit motive contributes to that ‘obsession for pursuing fashionable trends of dubious importance’. It would be great if we had more experimental antibiotics in the research pipeline, and it would be