Viagra Creep

Health and medicine explained.
May 15 1998 3:30 AM

Viagra Creep

Quality-of-life drugs may threaten more than insurers.

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The transformation of normal to abnormal may start with a pill. But the physician's need for diagnosis is what drives the process. Since the new quality-of-life drugs can have adverse health effects, the drugs need to come through physicians. But we don't give out drugs willy-nilly. We must provide a medical reason--a diagnosis. So we call impotence "erectile dysfunction," baldness "hypotrichosis," and so on. The rapid increase in attention-deficit disorder is a striking example of diagnosis creep. The disorder hardly seemed to exist before the stimulant Ritalin came along. A core group of kids do have a distinct attention abnormality, but Ritalin worked so well--it can reduce distractibility even in perfectly normal children--that now almost any "difficult" child is considered for the diagnosis and drug. A 1990 study found that 28 percent of children diagnosed with the disorder didn't actually meet the definition. Nevertheless, the percentage of children on Ritalin has doubled since then.

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By giving a patient's condition a medical name, we turn it into a medical abnormality. That creates a presumption that insurers must pay. It also creates a presumption that it will be treated. If I write a new diagnosis in a patient's chart, I have to indicate what I plan to do about it. It'd be malpractice not to. More than that, once a condition is established as a diagnosis, society practically treats it as a crime not to do something about it.

This raises an ironic prospect. Quality-of-life drugs offer not just the pleasing possibility that you can do something about impotence, baldness, blackened toenails. They create a culture in which you must fight against these conditions--even if it means risking serious side effects (the anti-fungal drugs for nails can damage the liver, Propecia's anti-testosterone action can decrease libido). By their sheer effectiveness, the quality-of-life drugs narrow the range of what society accepts as normal. In doing so, they may ultimately reduce the quality of life for the many of us who are less than perfectly endowed.

If you missed the sidebar on how Viagra works, click.

Atul Gawande, M.D., writes a regular column on science and policy for Slate.