Self-Medication and Society

Mirages of Autonomy

Sylvie Fainzang

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781315447148
• Edition: 1
• Topic: Sciences sociales
• Subtopic: Sociologie

The question of recourse to self-medication arises at the intersection of two partly antagonistic discourses: that of the public authorities, who advocate the practice primarily for economic reasons, and that of health professionals, who condemn it for fear that it may pose a danger to health and dispossess the profession of expertise. This books examines the reality of self-medication in context and investigates the social treatment of the notion of autonomy ever present in the discourses promoting this practice.

Drawing on fieldwork conducted in France, the author examines the material, cognitive, symbolic and social dimensions of the recourse to self-medication, considering the motivations and practices of the subjects and what these reveal about their relationship with the medical institution, while addressing the question of open access to medicines – a subject of heated debate between the actors concerned on themes such as competence, knowledge and responsibility.

A rigorous analysis of the strategies adopted by individuals to manage the risks of medicines and increase their efficacy, Self-Medication and Society will appeal to sociologists and anthropologists with interests in health, illness, the body and medicine.

1On the other side of the counter

To the joy of some and the sorrow of others, the French law of 30 June 2008 authorised open access to a certain number of medicines (Ministère de la santé, 2008). The question of open access engenders lively debates concerning access to non-prescription medicines on one hand, and direct access to medicines sold in pharmacies, not from behind the counter but in the users’ space – also called, ‘over the counter’ – on the other. The debate becomes even more animated when the question of open access to drugs is coupled with that of their distribution, and when supermarkets attempt to challenge the monopoly of pharmacies on these products.

The stakes in the first part of the debate relate to the possibility that the subjects might do without a medical prescription for some medicines; those in the second part concern the possibility that the subjects might, under certain conditions, do without the mediation of a pharmacist and the third part deals with the potential for the subjects to do without their advice. In all of these cases, the different forms taken by this controversy centre on the question of the subjects’ capacity to decide for themselves to acquire some types of medicines.

The economic dimension of this controversy is evident. It is indeed a deciding factor for some actors since self-medication generally involves the users paying for their own medicinal consumption. However, whether the actors are state legislators, the pharmaceutical industry, pharmacists, doctors or users, they all invoke a plethora of other reasons and arguments to make their cases. The link between the three parts, or levels of this debate (for or against self-medication, for or against open access to medicines and for or against medicinal sales in supermarkets), lies in the fact that one can contain the other without the opposite being necessarily the case. Thus, open access requires self-medication, but self-medication does not necessarily imply ‘over the counter’ access to medicines. Likewise, supermarket sales require open access which does not however necessarily imply that the drugs will be available in general stores. Thus the different levels of the controversy interlock to such a point that, in the debate at the second and third levels, the actors often mobilise arguments that endorse or denounce the object of the debate at a previous level.

The anthropologist’s role when faced with this debate is not to take sides but to listen to the different voices being expressed and study the stakes and rationalities motivating them. It is thus not a case of joining the debate by adding another voice but of using a social science perspective to examine the discourses arising from this controversy. Here I will examine the positions and arguments of the different groups of actors concerned (public authorities, pharmaceutical industry, doctors, pharmacists and users) as they are expressed in the public sphere in order to grasp the cognitive, symbolic and ideological mechanisms so as to define the values that govern them and the logics that underpin them. To do this, I will mine resources from public statements, official websites, external communication documents and Internet discussion forums. Beyond the potential contradictions and ambiguities contained in these discourses, we will see, on one hand, that while they rely on some of the most popular values of our times, such as autonomy and responsibility, these values are sometimes invoked to defend opposing positions and, on the other hand, that the way they are used leads simultaneously to a limitation in their scope.¹

The actors’ positions

Public authorities

In order to reduce healthcare spending, the public authorities have adopted various measures to encourage the use of self-medication. Thus, they have taken a wide range of drugs off the list of medicines eligible for reimbursement and enacted a decree² promoting open access to 217 of them.³ These measures are coupled with a discourse inviting patients to take responsibility for their ailments ‘in benign situations’. Pursuant to this decree, which allows direct access to these medicines, pharmacists can now assign a space especially for over-the-counter drugs in their dispensary. This decision was made after the publication of a report on self-medication, called the Coulomb report, which recommended that the self-medication domain be organised by encouraging health professionals to support access to (i.e. ‘accompany’ the patient in his/her choice of) medicines in the pharmacy (Coulomb and Baumelou, 2007).

For the health ministry, the aim in facilitating direct access to medicines is primarily economic. The decision to remove eligibility for reimbursement from a series of medicines was intended to increase the proportion the users pay of their medicinal expenditure. With this new decree, the health minister said she wanted to make savings in health insurance costs and allow everyone to ‘choose and compare’ (La Mutualité Française, 2007). The idea of ‘choice’ is clear: the stated objective in allowing open access for certain pharmaceutical products is to promote competition in drug prices and, supposedly, to improve user buying power. In this way, the public authorities subscribe to the strategy of transferring state spending to the users in order to reduce public health insurance costs. But this measure comes with some precautions. It is not simply a case of ‘offering competitive public prices and improving citizen buying power’, but also of ‘improving patient access to quality, appropriate information on the drugs they use without medical consultation’, of ‘offering them an informed choice accompanied with personalised advice’, and of ‘maintaining all the guarantees of accessibility, availability, and health safety provided by the pharmacies in France’ (Health Ministry, 2008). The Coulomb report proposes that doctors play a part in these safety measures, that they should ‘play a role of informing and advising’ and ‘also of verifying medicinal consumption, including outside of their own prescriptions’. Noting the information in the Coulomb report’s chapter on international comparisons, the public authorities deplore that France is lagging behind in the domain of self-medication. Despite the growth in the self-medication market in the last few years (Blenkisopp and Bradley, 1996), the report notes that medicinal spending on self-medication products in France is low and relatively less than in other European countries (27 euros per person per year as opposed to 60 euros in Germany and 40 in the UK and Italy) (Le Pen, 2007).

Finally, as in the rhetoric of the Coulomb report, the public authorities perceive self-medication to be part of a ‘responsible’ economic policy on medicines and as one of the important elements in ‘citizen responsibilisation’. The discourses expressed and the texts circulated in support of the decree in fact not only promote ‘patient responsibility’, but also their ‘capacity’⁴, and reiterate their intention of ‘accompanying patients in their desire to be actors in their health’ (Health Ministry, 2008). We will return to this point.

The pharmaceutical industry

The pharmaceutical industry, represented in particular by Afipa (Association Française de l’Industrie Pharmaceutique pour une Automédication responsable/French Association of the Pharmaceutical Industry for Responsible Self-medication) and LEEM (Les Entreprises du Médicament/The pharmaceutical companies), supports the development of self-medication which it considers to be an ‘important element of competitiveness for Europe and France’ (Afipa, 2004). Bernard Lemoine, the vice-president delegate of LEEM, said: ‘It is a fact today that most of the medicinal industry approves of the principle of self-medication, of family medication, meaning spontaneous drug purchases at the pharmacy’ (La Mutualité Française, 2007). The industry is also largely in favour of open access to medicines. Afipa itself has long been lobbying for medicines to be available to consumers and placed on their side of the counter. But, like the public authorities, the industry defends the pharmacy monopoly on drug distribution⁵ and recommends ‘using a strong brand policy […] to associate doctors with the promotion of self-medication’ and to facilitate ‘the oversight they can provide concerning the various medicines the patient is taking’.

Beyond the economic stakes of its position in the debate (Wallach, 2001), the industry tends to position itself in human, even political, terms by declaring that ‘responsible’ self-medication should be encouraged in order to ‘meet the growing desire of individuals to take charge of their health’ (Afipa, 2007). As Polillo and Mallet (2007) noted, ‘the patient-consumer is both in opposition to and combined with the user-citizen, whose autonomy is asserted but who is simultaneously exploited in public policies and in professional, but above all, industrial strategies’.

For the industry, making patients ‘responsible individuals’ means making them choice-driven consumers, but it also means demonstrating a willingness to respond to patient demands. Thus the representative of Bayer Santé familiale declared: ‘mind-sets are changing; […] the French are convinced of the need to take care of their health capital in a responsible and more autonomous way’ (Gautier, 2008), and Magalie Flachaire, the General Delegate of Afipa, said ‘we are starting from the observation that our co-citizens are capable of identifying small health problems and taking them in hand….’ (Afipa, 2007). The industry therefore asserts both patient rights and patient competence.

The doctors

According to an Afipa-Institut Louis Harris inquiry in 2004, 57 per cent of doctors are supportive of self-medication. They think that ‘excessive time’ is dedicated to ‘small complaints’ within their practices, and that this ‘precious time’ could be given over to prevention and caring for more serious pathologies (Afipa, 2004). We can easily imagine indeed that some doctors support self-medication in that it would empty their waiting rooms somewhat and allow them to respond more rapidly to the consultation needs of patients with serious pathologies. This is a powerful argument in the context of a deficit in the medical demography where self-medication could be a means of mitigating the shortage of doctors. This position is defended by the economist Claude Le Pen, for whom self-medication is a solution to the declining medical demography which makes accessing a doctor more difficult (Le Pen, 2003).

However, many doctors express strong reservations regarding self-medication. The French Medical Association bulletin echoed this feeling by saying that while it has ‘some advantages’, it also carries ‘numerous adverse effects’ (Pouillard, 2001). While self-medication ‘can be tolerated when it extends an already established therapy’ and can be ‘useful to temporarily attenuate a troublesome condition with a short-term medication, while waiting for a medical opinion, […] it can become very dangerous if it is used for an extended period, if a medical consultation is not sought or if it is used imprudently’ (Pouillard, 2001). Thus, self-medication is often considered to be a ‘risky practice’, risks resulting from ‘prescriptions without specific therapeutic justification’ or ‘non-controlled practices of self-medication that do not follow the rules of use: no verification of posology, treatment duration, medicinal interactions, iatrogenic or allergic reactions or medicinal expiry dates (family pharmacy cabinets)’. Michel Chassang, the president of the Confederation of French Medical Syndicates, believes that the development of self-medication leads a symptom to be associated with a medicine, an association which is detrimental to appropriate healthcare for the patient. As such, he thinks it is both dangerous and can foster illusions. He is worried about ‘the evolution of our society where bypassing the doctor has become a national sport’ (La Mutualité Française, 2007). Moreover, many doctors fear the potential for diagnostic delay inherent in self-medication, since patients are not capable, they believe, of knowing the difference between a benign symptom and a serious one. And so, they think patients should turn to their expertise since their knowledge is indispensable to appropriate healthcare provision, for all pathologies.⁶ In these conditions, open access is even more disapproved of by the majority of doctors. Yet, subjects are partly socialised and coached in self-medication by some doctors themselves. In this regard, the medical body is not homogenous.⁷ The majority however consider that despite ‘the dangers linked to consumer ignorance’, the medical world ‘should today take the practice of self-medication into account’, and that it ‘should be guided by precise advice to ill people’ (Queneau et al., 2004), in consideration of their ‘demand for autonomy’.

Pharmacists

In a debate initiated on the Internet by the 60 millions de consommateurs magazine concerning open access to medicines,⁸ in which numerous pharmacists took part, an assortment of opinions can be found. Some were outright hostile to self-medication itself, others to open access to medicines, or to drug sales in supermarkets, covering all three parts of the controversy. Some were in line with the industry, others took the doctors’ side, while a third group took intermediary positions – being in favour of self-medication for example but against open access. On the other hand, as can be expected, they all condemned supermarket sales, though for very different reasons. The positions against self-medication itself are most often justified by evoking the danger it represents: ‘It is in the USA that there are the most hospitalisations resulting from self-medication. No medicine is harmless! They are all dangerous!’ one pharmacist said (60 millions, 2008). Others accept the idea of self-medication but not open access, even for cases said to be ‘benign’. One pharmacist wrote: ‘self-service sales of harmful molecules are inadmissible’, and used as an example the fact that ‘taking aspirin when pregnant can seriously harm the fœtus’. Another web user pointed out that ‘a sore throat and a headache can be the first signs of scarlet fever’, and that ‘to avoid complications, a correct treatment must be administered as soon as the symptoms appear, symptoms that require serious investigation’. This is indeed the point of view of the National Academy of Pharmacy (2006) who stated that open access is ‘an imprudence detrimental to public health, considering the long-standing habits of our country’, and who, on this basis, is against leaving drugs of any sort in open access, even within a pharmacy.

While some pharmacists approve of self-medication, they nevertheless all stress, loud and clear, the importance of their role in advising consumers which potentially implies that the medicines should be kept behind the counter. Their hostility to open access is sometimes linked to the risk that it could boost consumption (Légaré, 2008). Thus, for F. Abecassis, the spokesperson for the Pharmaciens en colère collective (‘Angry Pharmacists’), medicines are not everyday c...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• Introduction
• 1 On the other side of the counter
• 2 Self-medication, between signs and symptoms
• 3 Cultural and practical reasons
• 4 Knowledge and competence
• 5 Risk management and the quest for efficacy
• Conclusion
• Bibliography
• Index