Patient empowerment and the dilemmas of late-modern medicalisation.

In Medical Nemesis, 1 perhaps the most infl uential defi nition of medicalisation ever written, historian-philosopher Ivan Illich argued that by overextending its scientifi c and cultural authority, modern medicine had itself become a threat to health, a fount of " doctor infl icted injuries " and " iatrogenic disease ". 1 Although Illich's 1975 book focused mainly on the role of the medical profession in creating these problems, he suggested that the ill eff ects of medicalisation might well be reversed by the actions of a long " passive public " , now beginning to recover its " will to self-care ". 1 The deepening crisis of modern medicine presented new opportunities for " the layman eff ectively to reclaim his own control over medical perception, classifi cation, and decision-making, " a " laicisation of the Temple of Aesculapius " that Illich believed held great promise for the reform of modern medicine. Read afresh in 2006, Illich's emphasis on laicisation seems remarkably prescient in some ways. Since the 1970s, patient activists in the USA and Europe have aggressively asserted their claims to be regarded as experts on their own illnesses and to play a more active part in health-care decision-making. Patient initiatives have resulted in monumental changes in the practice of medicine, including the legalisation of abortion, living wills, hospice care, hospital bills of rights, lumpectomies, experimental clinical trials, and expanded access to a vast array of consumer health information, to name only a few examples. Although many physicians initially resisted the idea of increased patient participation, lately they have become reconciled to, sometimes even enthusiastic about, the idea of the patient as partner. In developed countries, patients are now expected to take an active role in their care, and to be treated as important stakeholders in policy debates. 2 Yet contrary to Illich's 1970s optimism, increasing the role of patients in clinical decision-making has not been the solution for the many problems that beset late modern medicine in developed countries. The advent of patient-centred medicine has come at such a troubled point in history that its achievements are in danger of being negated. Although patient initiatives have secured the expansion of some kinds of choices and safeguards, especially for the educated and affl uent, they have been off set by growing demands for cost containment and market discipline that have limited the autonomy of both physicians and patients. …