Medicine's traditional focus on diagnosing and treating illness has succeeded in increasing life expectancy significantly. More recently, however, life expectancy in developed countries—particularly the United States—has slowed in its growth and is predicted by some to enter a decline in the coming decade, a phenomenon that can be attributed partly to the higher prevalence of chronic conditions such as obesity, hypertension, diabetes, and cardiovascular disease . In a certain sense, it is not incorrect to say that a different approach—prevention—may contribute as much to further improvements in quality and quantity of life as curative medicine.
Preventive medicine is integrated into routine medical care and garners much attention from the media on topics that range from smoking cessation to the controversial ban on trans fats. Most of us have been confronted with prevention in our own medical encounters—counseled to exercise more, for example, follow a better diet, or monitor our own health by breast or testicular self-exams—despite having no overt symptoms or health complaints. How many girls and young women have been offered the HPV vaccine? How many older patients have been prescribed pravastatin to help control their cholesterol or an ACE-inhibitor to lower their blood pressure? As the media continue to fight the so-called "obesity epidemic" and hospitals across the country enact smoking bans, it is not surprising that prevention has emerged as one of the most debated topics in medicine. And its consequences, for both the individual and society, are subjects of moral, financial, practical, and ethical scrutiny.
The focus on prevention represents an essential next step for the medical field, but its implementation has raised many concerns and been met with a fair share of criticism and ethical inquiry. Preventive medicine differs from traditional medicine in that its goals are to identify and control risk factors of disease rather than diseases themselves. Implementing preventive measures often means intervening in patient behavior or administering treatment before the onset of symptoms—a measure seen by some as a benefit to public health and by others as an intrusion into personal freedom. Because of this fundamental difference, preventive practice treads upon contested ethical grounds. This issue of Virtual Mentor delves into the ethical questions prevention raises and provides insight on how such questions might be tackled in the future by physicians and medical students.
Ethical questions in preventive medicine reach far and wide, touching physicians, patients, employers, insurers, hospital administrators, policy makers, and society. The three clinical cases in this issue present concrete dilemmas that physicians face in balancing treatment of individual patients with preventive measures that, in general, have wider population goals. Case 1 discusses the conflicts that can arise when prevention becomes the rule for directing physicians' practices and a measure for evaluating their performance. Case 2 examines the challenges that a hospitalwide smoking ban poses to physicians caring for smokers and considers the tensions between hospital policy and the treatment of an individual patient. Case 3 considers expedited partner therapy for sexually transmitted diseases and weighs the physician's obligations to prescribe only for those with whom he has established a patient-physician relationship against his duties to promote public health.
The interplay between insurers and employers in preventive medicine is further explored in the health law and op-ed pieces as well as in the winning entry in the Conley Ethics Essay Contest for medical students. The health law article explains why legal challenges to employer-imposed restrictions on employee smoking have failed. The op-ed presents an overview of the currently attempted carrot and stick methods for encouraging prevention by providing benefits or curtailing privileges based on patient and physician compliance. The winning Conley contest essay seeks to define the physician's role when a patient has been penalized by an employer-based wellness program.
The medicine and society article elaborates on the physician's role—and perhaps obligation—in counseling patients about how to overcome financial obstacles to healthier lifestyles and access to care.
The clinical pearl identifies the characteristics of hypertension and prehypertension and describes preventive practices for managing these widespread conditions. More unusual and controversial applications of preventive medicine are examined in the policy forum, which considers the validity of introducing preventive measures typically reserved for adults into the pediatric population, and the journal discussion, which considers the implications of prevention in the psychiatric and psychological realms through use of drugs to suppress formation of bad memories and prevent posttraumatic stress disorder.
Given the myriad everyday applications of prevention as well as its more rare and contested uses, it is clear that preventive medicine has taken root in today's society and will become a health care centerpiece. Moreover, the prevalence of preventable acute and chronic illness that dominates health care suggests that there is a great need for this focus. Unfortunately, the United States suffers from an appalling shortage of physicians specifically trained in preventive medicine, as the medical education piece affirms in highlighting the shortcomings of preventive medicine education and the need to direct more resources to this field.
As more Americans succumb to the epidemics of chronic disease, and improvements in science allow us to identify more concrete risk factors, prevention will continue to gain momentum. More ethical dilemmas surrounding prevention will surely emerge in the clinical, financial, and administrative settings, and it is my sincere hope that this issue of Virtual Mentor will help to engage the medical community, and particularly medical students and residents, in a dialogue about the application of preventive medicine to our society.
- Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med. 2005;352(11):1138-1145.