Differentiating clinical care from disease prevention: a prerequisite for practicing quaternary prevention

Charles Dalcanale Tesser,Armando Henrique Norman

doi:10.1590/0102-311x00012316

Charles Dalcanale Tesser, Armando Henrique Norman

Open Access

https://doi.org/10.1590/0102-311x00012316

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Abstract

This article contends that the distinction between clinical care (illness) and prevention of future disease is essential to the practice of quaternary prevention. The authors argue that the ongoing entanglement of clinical care and prevention transforms healthy into "sick" people through changes in disease classification criteria and/or cut-off points for defining high-risk states. This diverts health care resources away from those in need of care and increases the risk of iatrogenic harm in healthy people. The distinction in focus is based on: (a) management of uncertainty (more flexible when caring for ill persons); (b) guarantee of benefit (required only in prevention); (c) harm tolerance (nil or minimal in prevention). This implies attitudinal differences in the decision-making process: greater skepticism, scientism and resistance towards preventive action. These should be based on high-quality scientific evidence of end-outcomes that displays a net positive harm/benefit ratio.

Highlights

Quaternary prevention (P4) are the actions taken for identifying people at risk of over-medicalization, in order to protect them from new medical invasion and to propose ethically acceptable alternatives
As a critical synthesis stemming from primary health care professionals, the P4 proposition can lead to changes in preventive practices at all levels of prevention, by suggesting attitudes and systematizing the available scientific knowledge for coping and managing the overemphasis on prevention, medicalization, and its excessive iatrogenic effects 4
Biomedical “additive” preventive activities in asymptomatic cases are fundamentally distinct from clinical care, and must remain so

Summary

Introduction

Quaternary prevention (P4) are the actions taken for identifying people at risk of over-medicalization, in order to protect them from new medical invasion and to propose ethically acceptable alternatives. We contend that the practice of P4 requires the distinction between clinical care of the sick and preventive actions in asymptomatic, i.e. specific primary and secondary prevention 12, such as disease screening. This distinction is systemized in three main topics: (a) the biomedical process of merging prevention into clinical care; (b) technical-ethical differences of these two health care activities; and (c) the attitudinal implication for both policy-makers and health professionals by establishing this distinction.

Results

Conclusion