A lot of money can be made from healthy people who believe they are sick. Pharmaceutical companies sponsor diseases and promotethem to prescribers and consumers. Ray Moynihan, Iona Heath, andDavid Henry give examples of "disease mongering" and suggest howto prevent the growth of this practice

There's a lot of money to be made from telling healthy people they're sick. Some forms of medicalising ordinary life may nowbe better described as disease mongering: widening the boundariesof treatable illness in order to expand markets for those whosell and deliver treatments. ^{1 2} Pharmaceutical companiesare actively involved in sponsoring the definition of diseasesand promoting them to both prescribers and consumers. The socialconstruction of illness is being replaced by the corporate construction ofdisease.

Whereas some aspects of medicalisation are the subject of ongoing debate, the mechanics of corporate backed disease mongering,and its impact on public consciousness, medical practice, humanhealth, and national budgets, have attracted limited criticalscrutiny.

Within many disease categories informal alliances have emerged, comprising drug company staff, doctors, and consumer groups.Ostensibly engaged in raising public awareness about underdiagnosedand undertreated problems, these alliances tend to promote a viewof their particular condition as widespread, serious, and treatable.Because these "disease awareness" campaigns are commonly linkedto companies' marketing strategies, they operate to expand markets for new pharmaceutical products. Alternative approaches emphasisingthe self limiting or relatively benign natural history of a problem,or the importance of personal coping strategies are played downor ignored. As the late medical writer Lynn Payer observed, diseasemongers "gnaw away at our self-confidence."²

Although some sponsored professionals or consumers may act independently and all concerned may have honourable motives, inmany cases the formula is the same: groups and/or campaigns areorchestrated, funded, and facilitated by corporate interests,often via their public relations and marketing infrastructure.

A key strategy of the alliances is to target the news media with stories designed to create fears about the condition or diseaseand draw attention to the latest treatment. Company sponsoredadvisory boards supply the "independent experts" for these stories,consumer groups provide the "victims," and public relations companiesprovide media outlets with the positive spin about the latest "breakthrough"medications.

Inappropriate medicalisation carries the dangers of unnecessary labelling, poor treatment decisions, iatrogenic illness, andeconomic waste, as well as the opportunity costs that result whenresources are diverted away from treating or preventing more seriousdisease. At a deeper level it may help to feed unhealthy obsessionswith health,³ obscure or mystify sociological or politicalexplanations for health problems,⁴ and focus undue attentionon pharmacological, individualised, or privatised solutions.³ More tangibly and immediately, the costs of new drugs targetedat essentially healthy people are threatening the viability ofpublicly funded universal health insurance systems.⁵

Recent discussions about medicalisation⁶ have emphasised the limitations of earlier critiques¹ of the disabling impactof a powerful medical establishment. Contemporary writers arguethat the lay populace has become more active, better informedabout risks and benefits, less trusting of medical authority, and less passively accepting of the expansion of medical jurisdictioninto their bodies and lives. Although these views may herald amore mature debate about medicalisation, the erosion of trustin medical opinion reinforces the need for wide public scrutinyof industry's role in theseprocesses.

In this paper we do not aim for a comprehensive classification or definitive description of disease mongering, but ratherwe draw attention to an important but under-recognised phenomenon.We identify examples, taken from the Australian context but familiarinternationally, which loosely represent five examples of disease mongering: the ordinary processes or ailments of life classifiedas medical problems; mild symptoms portrayed as portents of aserious disease; personal or social problems seen as medical ones;risks conceptualised as diseases; and disease prevalence estimatesframed to maximise the size of a medical problem. These groupsare not mutually exclusive and some examplesoverlap.

	Ordinary processes or ailments as medical problems: baldness

The medicalisation of baldness shows clearly the transformation of the ordinary processes of life into medical phenomena.Around the time that Merck's hair growth drug finasteride (Propecia)was first approved in Australia, leading newspapers featured newinformation about the emotional trauma associated with hair loss.The global public relations firm Edelman orchestrated some ofthe coverage but largely left its fingerprints off the resulting stories. An article on page 4 in the Australian newspaper featureda new "study" suggesting that a third of all men experienced somedegree of hair loss, along with comments by concerned expertsand news that an International Hair Study Institute had been established.⁷ It suggested that losing hair could lead to panic and other emotionaldifficulties, and even have an impact on job prospects and mentalwellbeing. The article did not reveal that the study and the institutewere both funded by Merck and that the experts quoted had beensupplied by Edelman, despite this information being availablein Edelman's publicity materials in May 1998. 

Although Merck is prevented from advertising finasteride direct to consumers in Australia, it has continued to promote hairloss as a medical problem, with waves of advertisements urgingbalding men to "See Your Doctor." The company argues that it doesnot describe baldness as an illness and that men have a legitimateright to be made aware of scientifically proved options to stophair loss (statement from Merck spokesperson, 7 March 2002).

Mild symptoms as portents of serious disease: irritable bowel syndrome

Irritable bowel syndrome has long been considered a common functional disorder, and a "diagnosis of exclusion" covering arange of symptom severity, yet it is currently experiencing somethingof a global "makeover." Without question many people with thecondition are severely disabled by their symptoms, but the arrivalof new drugs has seen manufacturers seek to change the way theworld thinks about irritable bowelsyndrome.

What for many people is a mild functional disorder requiring little more than reassurance about its benign natural course is currently being reframed as a serious disease attracting a labeland a drug, with all the associated harms and costs.

Confidential plan to "shape" medical opinion
A confidential draft document leaked froma medical communications company, In Vivo Communications, describes a three year "medical education programme" to create a new perceptionof irritable bowel syndrome as a "credible, common and concretedisease." The proposed 2001-3 education programme is part of themarketing strategy for GlaxoSmithKline's drug Lotronex (alosetron hydrochloride).

In Vivo is one of a handful of companies specialising in corporate backed "medical education," and the leaked plan providesa rare insight into the highly secretive world of drug promotion,with its new emphasis on "shaping" medical and public opinionabout the latest diseases.

According to the documents, the education programme's key aim is this: "IBS [irritable bowel syndrome] must be establishedin the minds of doctors as a significant and discrete diseasestate." Patients also "need to be convinced that IBS is a commonand recognised medical disorder." The other main messages areabout promoting the new "clinically proven therapy" Lotronex.

The first step is to set up an "Advisory Board, comprising one KOL [key opinion leader] from each state of Australia." Itschief role would be to provide advice to the corporate sponsorson current opinion in gastroenterology and on "opportunities forshaping it." Further work would include developing "best practice guidelines" for diagnosing and managing irritable bowel syndromeand attending overseas meetings. Another strategy was to producea newsletter in the pre-launch period to "establish the market"and convince the "specialist market" that the condition is a "seriousand credible disease."

For general practitioners, In Vivo recommends a series of advertorials in leading medical magazines, featuring interviewswith members of the company's advisory board, because "The imprimaturof [board] members is invaluable in reassuring [general practitioners] . . . that the material they receive is clinicallyvalid."

Other groups to be targeted with promotional material include pharmacists, nurses, patients, and a medical foundation describedas already having a "close relationship" with In Vivo. A "patientsupport programme" is also planned for 2002-3, so that GlaxoSmithKline will "reap the loyalty dividend when the competitor drug kicksin."

Medical education or marketing?
Although billed as a medical education plan,the document is clearly part of the Lotronex marketing strategy.One clause explicitly stipulates that all publications and manuscriptsmust be approved by the drug company's marketing, medical, andlegal departments. The document also makes clear the media's rolein changing public perceptions about irritable bowel syndrome,stating that "PR [public relations] and media activities are crucial to a well-rounded campaign particularly in the area of consumerawareness."

Whatever the integrity or competence of the professionals or consumer advocates involved, and without seeking to minimisethe importance of the disorder for some individuals, this planshows that staff and organisations sponsored by a drug companyare helping to shape medical and public opinion about the conditionthat company is targeting with its new product. Although GlaxoSmithKline has argued that its sponsorship of education can improve doctors'prescribing habits (personal communication, 7 March 2002), theconflict of interest is obvious and potentially dangerous. Selfevidently, the drug company's primary interest will be shapingopinion about irritable bowel syndrome in a way that will maximisesales of itsmedication.

In this case the proposed campaign was stopped because of the withdrawal of Lotronex from the market, after reports to theUS Food and Drug Administration of serious and sometimes fataladverse reactions.⁸ In a recent letter to patients, the administration suggested that indiscriminate use of the drug could result inmore fatal adverse events and that many patients in whom the conditionwas non-serious could experience more harm than good.⁹

Conversations with industry insiders and other published material from the drug marketing industry confirm that the strategiesproposed for promoting irritable bowel syndrome by In Vivo werein no way exceptional. A "practical guide" published by Britain'sPharmaceutical Marketing magazine last year explicitly emphasisedthat key objectives of the pre-launch period were to "establisha need" for a new drug and "create the desire" among prescribers.¹⁰ The guide instructed drug marketers that they may need to "initiatea review of the whole way in which a particular disease ismanaged."

Personal or social problems as medical ones: social phobia

When Roche was promoting its antidepressant Aurorix (moclobemide) as a valuable treatment for social phobia in 1997, its publicrelations company issued a press release, picked up by some ofthe media, announcing that more than one million Australians hadan underdiagnosed psychiatric disorder called social phobia.¹¹ The release described a "soul destroying condition" and quoteda clinical psychologist strongly endorsing the role of antidepressantsin its treatment. At that time, government figures suggested thenumber of people with the disorder might be closer to 370000.

In 1998, a newspaper article, "Too shy for words" this time not orchestrated by Roche suggested that two million Australianswere affected by the condition.¹² All the media stories seemedto be part of a wider push to change the common perception ofshyness, from a personal difficulty to a psychiatricdisorder.

An important aspect of Roche's marketing for moclobemide involved working with a patient group called the Obsessive Compulsiveand Anxiety Disorders Foundation of Victoria and funding a largeconference on social phobia. According to the foundation's chiefat the time, "Roche is putting a lot of money into promoting socialphobia . . . Roche funded the conference to help get social phobiaknown among [general practitioners] and other health professionals. . . It was a vehicle to raise awareness with the media too."¹¹ Roche's promotion of its antidepressant drug also included workingwith ostensibly independent medical specialists, one of whom waslater described by a public relations agent as "Moclobemide Man"(personal communication, 1998).

Pharmaceutical Marketing's practical guide singled out the promotion of social phobia as a positive example of drug marketersshaping medical and public opinion about a disease.¹⁰ "You mayeven need to reinforce the actual existence of a disease and/orthe value of treating it. A classic example of this was the needto create recognition in Europe of social phobia as a distinctclinical entity and the potential of antidepressant agents suchas moclobemide to treat it," said the industry guide. It wenton: "Social phobia was recognised in the US and so transatlantic opinion leaders were mobilised to participate in advisory activities,meetings, publications etc. to help influence the overall beliefin Europe." The medicalisation of human distress seems to haveno limits.¹³

A senior Roche official recently conceded that company promotion exaggerated the prevalence of social phobia in Australia."A lot of disease estimates are blown out of all proportion . . . The marketing people always beat these things up" said localmanaging director Mr Fred Nadjarian (see newsarticle).

Risks conceptualised as diseases: osteoporosis

Like high blood pressure or raised cholesterol levels, the medicalisation of reduced bone mass which occurs as people age is an example of a risk factor being conceptualised as a disease.

Unlike medicalising baldness, conceiving osteoporosis as a disease is ethically complex. Slowing bone loss can reduce therisk of future fracture just as lowering blood pressure can reducea person's chance of a future stroke or heart attack but for mosthealthy people, the risks of serious fractures are low and/ordistant, and in absolute terms, long term preventive drug treatmentoffers small reductions in risk. For example, in a placebo controlledtrial in which alendronate was taken for four years by women whowere free of fracture but had bone mineral density measurements 1.6 standard deviations below the mean for normal young adultwhite women, the incidence of radiographic vertebral fractureswas 3.8% in the placebo group and 2.1% in the treatment group.¹⁴ This equated to a 44% relative reduction in risk but an absoluterisk reduction of only 1.7%.

Furthermore, the promotional focus on chemical solutions for the complex problem of preventing fractures takes attention awayfrom a variety of modestly effective non-pharmacological strategies,such as dietary supplementation with calcium and vitamin D, smoking cessation, and weight bearing exercise.¹⁵

Despite the ethical complexities, osteoporosis remains a strong example of disease mongering because the corporate role inchanging the way populations think about bone loss has been soextensive. Drug companies have sponsored meetings where the diseasewas being defined,¹⁶ funded studies of therapies,¹⁷ and developedextensive financial ties with leading researchers. They have fundedpatient groups, disease foundations, and advertising campaigns(on both drugs and disease) targeted at doctors¹¹ and have sponsoredosteoporosis media awards offering lucrative prizes tojournalists.

A controversial definition
Contrary to much of the corporate promotion,the definition of osteoporosis is still controversial. Diagnostic criteria set by the World Health Organization, which set the bonedensity of young white women as "normal" and judge the bones ofolder women against this standard, are contentious.¹⁶ A keymeeting of the WHO study group involved in defining the diagnosisof osteoporosis was funded in part by three pharmaceutical companies.¹⁶

The link between bone density and fracture risk is also the subject of scientific controversy, with reviewers pointing outthat while bone mineral density is associated with fracture, itis not a sufficiently accurate predictor of an individual's riskof fracture to be used as a guide to therapy.¹⁸ A recent evaluationby the University of British Columbia concluded that "Researchevidence does not support either whole population or selective. . . bone mineral density testing of well women at or near menopause as a means to predict future fractures."¹⁶

Good quality studies have shown that several drugs, including oestrogens, selective oestrogen receptor modulating agents,and bisphosphonates, reduce the risk of fractures.¹⁵ However,although public promotion of those drugs often relies on presentationsof relative reductions in fracture risk, the absolute reductionsfor healthy women are small when weighed against potential harmsand costs.¹⁹

The marketing of fear
Osteoporosis Australia, a medical foundation,which has received funding from pharmaceutical companies, issueda press release recently urging people to take a one minute test for their risk of osteoporosis.²⁰ According to the foundation,"we call this disease a silent thief: if you're not vigilant,it can sneak up on you and snatch your quality of life and yourlong-term health." An accompanying 10 point checklist suggests that merely being a menopausal woman was enough to justify a tripto the doctor to be tested for this disease. The constructionof the widely used WHO diagnostic criteria is such that largenumbers of healthy women at menopause will automatically be diagnosedas having this "disease" because their bones are being comparedwith those of much youngerwomen.

Against a background of controversy over disease definition, poor predictive value of bone density measurement, and heavilyadvertised expensive therapies offering marginal benefits to menopausalwomen, corporate backed promotional activities are attemptingto persuade millions of healthy women worldwide that they aresick.

Disease prevalence estimates framed to maximise the size of a medical problem: erectile dysfunction

Double page advertisements told Australians recently that 39% of men who visit general practitioners have erection problems.²¹ The advertisement featured an unhappy couple, who looked to bein their 30s or 40s, on opposite sides of a double bed, with theaccompanying text: "Erection problems: hard to talk about, easyto treat." As with much disease mongering, the key strategy herewas to make the condition seem as widespread aspossible.

The 39% claim in the advertisement was referenced to an abstract of a survey finding. The full version of the published survey²² revealed that the 39% figure was obtained by tallying all categoriesof difficulties, including men who reported having problems only"occasionally," and the average age of those reporting completeerectile dysfunction was 71 years. Another recent Australian study,not cited in the advertisement, estimated that erection problems affected only 3% of men in their 40s, and 64% of men in their70s.²³

The advertisement's fine print cited a host organisation, Impotence Australia, and two other groups but did not mention thatthe advertisement was funded by the manufacturer of sildenafil(Viagra), Pfizer. Impotence Australia had at that time only recentlybeen set up with a grant of $A200 000 (£74 000; $105 200; 119 400) from Pfizer. Its executive officer told the press, "I couldunderstand that people may have a feeling that this is a frontfor Pfizer."²⁴

Defending the public promotion of erection problems, a Pfizer spokesperson said, "The best consumer is an educated consumer. . . Who better than the manufacturer to help this process?"(personal communication, 5 March,2002).

Discussion

These observations of disease mongering are selective and preliminary. They are not the result of systematic study, but rathera series of anecdotal case studies designed to provoke debate.We know little of the true extent of these industry funded zonesof influence, and even less of their impact. But we believe moreinformation and analysis of the nature and functioning of these "unholy alliances"² is warranted. The key concern with theexamples here is the invisible and unregulated attempts to changepublic perceptions about health and illness to widen markets for newdrugs.

Although mainstream media already play an important role investigating and reporting on contemporary promotional activities,more could be done to expose and reduce misleading "wonder drug"stories, which help to facilitate so much diseasemongering.

As a practical step, we suggest that health professionals, policy makers, journalists, and consumers move away from relianceon corporate sponsored material about the nature or prevalenceof disease. Genuinely independent sources of information abouthealth problems could replace those skewed towards making themaximum numbers of healthy people feelsick.

Just as researchers from the Cochrane Collaboration are generating systematic evaluations of the best evidence about therapies,a similar effort may be required in evaluating and/or producingunbiased information about illness starting with those conditionsmost prone to disease mongering. Independent lay involvement iscrucial to produce accurate, comprehensive, and accessible materials.

The public is entitled to know about the controversy surrounding disease definitions and about the self limiting and relativelybenign natural course of many conditions. A publicly funded andindependently run programme of "de-medicalisation," based on respectfor human dignity, rather than shareholder value or professional hubris, is overdue.

Acknowledgments

We dedicate this article to the late Lynn Payer, medical writer, who died last year. We thank David Newby for his help inconducting literaturesearches.

Footnotes

Competing interests: DH has received funding from American Home Products to conduct research into non-steroidal anti-inflammatorydrugs. As a member of the Australian Pharmaceuticals BenefitsAdvisory Committee, he has has twice been the subject of legalaction by Pfizer.

References

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2.	Payer L. Disease-mongers. New York: John Wiley, 1992.
3.	Crawford R. Healthism and the medicalization of everyday life. Int J Health Services 1980; 10: 365-388
4.	Pilgrim D, Bentall R. The medicalisation of misery: A critical realist analysis of the concept of depression. J Mental Health 1999; 8: 261-274
5.	Gilbert D, Walley T, New B. Lifestyle medicines. BMJ 2000; 321: 1341-1344
6.	Williams S, Calnan M. The "Limits" of medicalization? Modern medicine and the lay populace in "late" modernity. Soc Sci Med 1996; 42: 1609-1620
7.	Hickman B. Men wise up to bald truth. Australian 1998 May 21:p4.
8.	US Food and Drug Administration. Glaxo Wellcome decides to withdraw Lotronex from the market. www.fda.gov/bbs/topics/ANSWERS/ANS01058.html (accessed 18 March 2002).
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11.	Moynihan R. Too much medicine? Sydney: ABC Books, 1998:137-168.
12.	Heath S. Too shy for words. The Age 1998 Mar 30:16. ("Living" section.)
13.	Heath I. There must be limits to the medicalisation of human distress. BMJ 1999; 318: 439-440
14.	Cummings SR, Black M, Thompson DE, Applegate WB. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the fracture intervention trial. JAMA 1998; 280: 2077-2082
15.	Wade JP. Rheumatology: 15. Osteoporosis. CMAJ 2001; 165: 45-50
16.	Green C, Bassett K, Foerster V, Kazanjian A. Bone mineral density testing: does the evidence support its selective use in well women? Vancouver, BC: British Columbia Office of Health Technology Assessment, 1997.
17.	Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 1996; 348: 1535-1541
18.	Wilkin TJ. Changing perceptions in osteoporosis. BMJ 1999; 318: 862-864
19.	Moynihan R, Bero L, Ross-Degnan D, Henry D, Lee K, Watkins J, et al. Coverage by the news media of the benefits and risks of medications. N Engl J Med 2000; 342: 1645-1650
20.	Osteoporosis take the time to take the test. Osteoporosis Australia News release, 6 Aug 2001.
21.	Advertisement. Sydney Morning Herald , 2000 21 Oct:76-7.
22.	Chew K, Earle C, Stuckey B, Jamrozik K, Keogh E. Erectile dysfunction in general medicine practice: prevalence and clinical correlates. Int J Impotence Res 2000; 12: 41-45
23.	Pinnock C, Stapleton A, Marshall V. Erectile dysfunction in the community: a prevalence study. Med J Aust 1999; 171: 353-357
24.	Moynihan R. Taking the soft option. Australian Financial Review 2000 Nov 13:29.

Ray Moynihan, journalist ^a, Iona Heath, general practitioner ^b, David Henry, professor of clinical pharmacology ^c. 

^a Australian Financial Review, GPO Box 506, Sydney, 2201, Australia, ^b Caversham Group Practice, 4 Peckwater Street, London NW5 2UP, ^c School of Medical Practice and Population Health, Faculty of Health, University of Newcastle, NSW 2308, Australia

Correspondence to: R Moynihan ray_128@hotmail.com

Commentary: Medicalisation of risk factors

Peter C Gøtzsche, director. 

Nordic Cochrane Centre, Rigshospitalet, 2100 Copenhagen Ø, Denmark

pcg@cochrane.dk

A middle aged man with pneumonia may wonder why the attending doctor is inserting a finger into his rectum. This is a screeningtest it has nothing to do with the patient's disease. The physician may find a localised prostate cancer, and the patient may subsequentlyundergo radical prostatectomy, although no evidence from randomisedtrials shows that this operation is effective. The patient withpneumonia cannot be sure that the prostatectomy will increasehis chance of living longer, but his life will probably feel longer,because the operation renders most men impotent.¹ This disastrousconsequence has received too little attention, but when properlyinformed, many men will decide not to have a screening test.²

The man's risk factor for prostate cancer was his age. Increased age leads to other unanticipated interventions. In some countries,women are invited for mammography in a letter in which the dateand time of the appointment have already been fixed. This putspressure on these women, who must actively decline the invitationif they don't want to be screened. Sometimes, women are askedto give reasons for not attending appointments, as if it werea civic duty. In leaflets, women get simple messages that cancerdetected early can be cured, and early cancers can often be treatedwith breast conserving surgery. The data tell another story: noreliable evidence shows that breast screening saves lives; breastscreening leads to more surgery, including more mastectomies;and estimates show that more than a tenth of healthy women whoattend a breast screening programme experience considerable psychological distress for many months. ^{3 4}

Senior scientists argue that this debate should not be taking place in public.⁵ This misguided paternalism makes us wonderwhy health professionals are so eager to intervene in healthy people's lives and about those people's own perspectives on risks.In Denmark, the most common cause of death from cancer among womenis no longer breast cancer but is now lung cancer, which is mainlyself inflicted.

It seems that every person aims to balance the rewards of taking risks against perceived hazards.⁶ This can probably explainwhy laws on wearing safety belts have not reduced deaths fromroad crashes. Such deaths now happen to those outside rather thaninside the vehicle probably because drivers who wear safety beltsfeel safer and drive faster or more carelessly than those whodo not.⁶

Another important consideration is the reliability of studies of risk. Increased risks are often reported in case-controlstudies, which do not reliably identify moderate increases inrisk. A much quoted and carefully done meta-analysis of case-controlstudies claimed to show a 30% increase in the risk of breast cancerafter induced abortion,⁷ but this was later refuted by a largecohort study.⁸ Most epidemiologists interviewed by Sciencesaid they would not take seriously a single study reporting a new potential cause of cancer unless it increased the risk byat least a factor of three; some even noted that the lower limitof the confidence interval should exceed 3.⁹ Nevertheless,lay people are influenced by increases in risk of 50-100%, andthis leads to much public anxiety and many negative changes inlifestyle. Some people, for example, will follow unappealing dietsor quit sports when told that their bone mineral density is low,even though these diets may not affect bone mineral density and inactivity increases the risk of fractures.

Mass intervention on a fragile basis may lead to mass harm. The main outcome of cancer screening trials disease specific mortality is unreliable and biased in favour of screening. ^{3 4 10} It thereforeseems prudent to show an effect of a screening programme on totalmortality in good randomised trials and to inform the public fullyabout the adverse effects before the programme is implemented.The biggest risk for the population right now may be the uncritical adoption of screening tests for cancer for example, for cervical,breast, prostate, colon, and lung cancer, ^{1 3 10 11} despitelack of evidence of an effect on total mortality. Precursors tocancer can be seen in most healthy people above middle age, andthe potential for screening to cause harm and lead to a diagnosisof "pseudo-disease" is frightening. Whether risk factors shouldbe turned into diseases also needs careful reflection for otherscreening tests for example, detection of mild hypertension ormild hypercholesterolaemia.

Perhaps it is time to rethink what life is all about and remind ourselves that most people are willing to run substantialrisks in their ordinary life to preserve their joy and autonomy.In Out of Africa, Karen Blixen wrote that the European wants toget insured against fate, whereas the African takes it as it comes.She also wrote: "Frei lebt wer sterben kann" [Those who can die live freely].

	Footnotes

   Competing interest: None declared.

References

1.	Stanford JL, Feng Z, Hamilton AS, Gilliland FD, Stephenson RA, Eley JW, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA 2000; 283: 354-360
2.	Wolf AM, Nasser JF, Wolf AM, Schorling JB. The impact of informed consent on patient interest in prostate-specific antigen screening. Arch Intern Med 1996; 156: 1333-1336
3.	Olsen O, Gøtzsche PC. Systematic review of screening for breast cancer with mammography (http://image.thelancet.com/lancet/extra/fullreport.pdf).
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5.	Horton R. Screening mammography setting the record straight. Lancet 2002; 359: 441-442
6.	Richens J, Imrie J, Copas A. Condoms and seat belts: the parallels and the lessons. Lancet 2000; 355: 400-403
7.	Brind J, Chinchilli VM, Severs WB, Summy Long J. Induced abortion as an independent risk factor for breast cancer: a comprehensive review and meta-analysis. J Epidemiol Community Health 1996; 50: 481-496
8.	Melbye M, Wohlfahrt J, Olsen JH, Frisch M, Westergaard T, Helweg Larsen K, et al. Induced abortion and the risk of breast cancer. N Engl J Med 1997; 336: 81-85
9.	Taubes G. Epidemiology faces its limits. Science 1995; 269: 164-169
10.	Black WC, Haggstrom DA, Welch HG. All-cause mortality in randomized trials of cancer screening. J Natl Cancer Inst 2002; 94: 167-173
11.	Raffle AE, Alden B, Mackenzie EF. Detection rates for abnormal cervical smears: what are we screening for? Lancet 1995; 345: 1469-1473