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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">&#8220;&#91;&#8230;&#93; He remained obstinately gloomy the whole afternoon&#59; wouldn&#8217;t talk to Lenina&#39;s friends &#40;of whom they met dozens in the ice-cream soma bar between the wrestling bouts&#41;&#59; and in spite of his misery absolutely refused to take the half-gramme raspberry sundae which she pressed upon him&#46; &#8220;I&#8217;d rather be myself&#44;&#8221; he said&#46; &#8220;Myself and nasty&#46; Not somebody else&#44; however jolly&#46;&#8221;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Brave new world- <span class="elsevierStyleItalic">Aldoux Huxley</span></span><p id="par0010" class="elsevierStylePara elsevierViewall">The limits of current Medicine are becoming more and more blurred as increasingly more advances are made&#46; Our focus begins to shift from what can we treat to what should we do treat as doctors&#46; Aldous Huxley&#44; a seminal author of the 20th Century&#44; predicted the <span class="elsevierStyleItalic">medicalization</span> of life events&#46; For instance&#44; unhappiness is nowadays treated with antidepressants&#46; We could speculate about which is our <span class="elsevierStyleItalic">soma</span> &#40;the ideal pleasure drug taken by everybody in Aldous Huxley&#8217; famous novel <span class="elsevierStyleItalic">Brave New World</span>&#41; nowadays&#44; but we do not need to look far&#58; the prescription of antidepressants has tripled from 1994 to 2003 in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Two atypical antipsychotics&#44; aripiprazol &#40;Abilify&#174;&#44; Otsuka&#44; Bristol-Myers Squibb&#41; and quetiapine &#40;Seroquel&#174;&#44; AstraZeneca&#41;&#44; and one antidepressant &#40;Duloxetine&#44; Cymbalta&#174;&#44; Eli Lillly&#41; are among the ten best selling prescription drugs in the U&#46;S&#46; &#40;<a id="intr0005" class="elsevierStyleInterRef" href="http://www.businessinsider.com/10-best-selling-blockbuster-drugs-2012-6%3Fop=1">http&#58;&#47;&#47;www&#46;businessinsider&#46;com&#47;10-best-selling-blockbuster-drugs-2012-6&#63;op&#61;1</a>&#41;&#46; This might lead one to think that massive <span class="elsevierStyleItalic">soma</span>-medication of the population has already occurred&#46; Has the <span class="elsevierStyleItalic">medicalization</span> of everyday problems gone too far&#63;</p><p id="par0015" class="elsevierStylePara elsevierViewall">People are using novel medications in dangerous ways&#59; for example&#44; some adolescents use cognitive enhancers to improve cognitive function and some have even died in the aftermath of Viagra<span class="elsevierStyleSup">&#174;</span> use&#46; On the other hand&#44; the pharmaceutical industry is very interested in developing <span class="elsevierStyleItalic">mood brighteners</span> or <span class="elsevierStyleItalic">happiness pills</span> to meet increasing demands&#46; And the lack of a prescription is hardly a problem anymore because you can easily get what you want at a modest price delivered to your door thanks to the Internet&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this context&#44; it is complicated to understand current <span class="elsevierStyleItalic">Medicine</span> without using three concepts&#58; <span class="elsevierStyleItalic">medicalization</span>&#44; <span class="elsevierStyleItalic">wish-fulfilling Medicine</span>&#44; and <span class="elsevierStyleItalic">disease mongering</span>&#46; Quite surprisingly&#44; there are no previous studies addressing the relationship among all three concepts&#46; The concept of <span class="elsevierStyleItalic">medicalization</span> gained importance in the seventies&#44; and it can still be considered a classical term in Sociology and Medicine&#46; In the eighties&#44; researchers began to speak about <span class="elsevierStyleItalic">wish-fulfilling medicine</span>&#46; Lastly&#44; the first article on <span class="elsevierStyleItalic">disease mongering</span> indexed in the PUBMED was published in 2002&#46; Could this latest interest on disease mongering reflect the preoccupation of researchers on the type of medically controlled societies we are creating&#63; Are we headed toward <span class="elsevierStyleItalic">a brave new world</span>&#63;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Medicalization&#58; from patients to clients</span><p id="par0025" class="elsevierStylePara elsevierViewall">Western societies are characterized by a growing <span class="elsevierStyleItalic">medicalization</span> of life events such as puberty&#44; menopause&#44; pregnancy&#44; aging&#44; or even death&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The term <span class="elsevierStyleItalic">medicalization</span> refers to problems previously regarded as normal or as a deviance of normal that are now regarded as &#8220;pathologized&#8221; life events&#44; such as menopause&#44; baldness&#44; or marital separation&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Specifically&#44; <span class="elsevierStyleItalic">medicalization</span> can be defined as &#8220;a process by which nonmedical problems become defined and treated as medical problems&#44; usually in terms of illnesses or disorders&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although it is difficult to establish when this term entered the social and medical vocabulary&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> its use expanded under the open-ended concept of health developed by the WHO in 1946 that stated that &#8220;Health is a state of complete physical&#44; mental and social well-being and not merely the absence of disease or infirmity&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This supposed a Copernican change&#44; as the traditional concept of health&#44; based on the presence&#47;absence of illness -the medical science behind the traditional medical model has evolved through five stages&#58; &#40;1&#41; symptoms&#44; &#40;2&#41; syndromes&#44; &#40;3&#41; tissue alterations&#44; &#40;4&#41; demonstration of the causes behind these tissues alterations&#44; and &#40;5&#41; treatment&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> was replaced by &#8220;a state of complete physical&#44; mental and social well-being&#8221;&#46; In other words&#44; <span class="elsevierStyleItalic">happiness</span>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">One of the areas where <span class="elsevierStyleItalic">medicalization</span> is clearly represented is <span class="elsevierStyleItalic">aging</span> and <span class="elsevierStyleItalic">death</span>&#46; Life expectancy at birth is growing worldwide&#44; particularly in industrialized countries&#46; Even though it is still currently impossible to change our genetic code in order to live longer&#44; we are not far from this possibility&#46; For instance&#44; modification of the daf2 gene can double the life span of worms&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The possibility of extrapolating these advances to human beings has raised serious ethical concerns&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> But&#44; not everyone concerns&#46; The American futurist Ray Kurweil has paid for his cryopreservation along with more than 800 millionaires just in case these advances are not in the foreseeable future &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://elpais.com/diario/2008/08/28/revistaverano/1219940508_850215.html">http&#58;&#47;&#47;elpais&#46;com&#47;diario&#47;2008&#47;08&#47;28&#47;revistaverano&#47;1219940508&#95;850215&#46;html</a>&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Medicalization</span> is also rooted in the field of mental disorders&#46; For instance&#44; individuals lacking personal resources to face certain life events &#40;i&#46;e&#46; marital discord&#41; are displacing the &#8220;usual&#8221; psychiatric patients &#40;i&#46;e&#46; those with schizophrenia&#41;&#46; Indeed&#44; adaptive disorders are the most frequent disorders in public mental health centers in the <span class="elsevierStyleItalic">Community of Madrid</span> &#40;Spain&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Another example is the <span class="elsevierStyleItalic">medicalization</span> of deviances&#44; such as&#44; hyperactivity and learning disabilities&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleItalic">Conrad</span> stressed that there were no hyperactive children in the People&#39;s Republic of China in the seventies whereas ten years later hyperactivity became the most prevalent diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Some of the forces behind <span class="elsevierStyleItalic">medicalization</span> are pharmaceutical companies economic interests&#44; but they do not stand-alone&#46; Physicians are being increasingly pressured by the insatiable demands of their patients &#40;or users&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Indeed&#44; one of the consequences of <span class="elsevierStyleItalic">medicalization</span> is the transition from patients to <span class="elsevierStyleItalic">clients &#40;users&#41;</span>&#46; Clients are more pro-active in making decisions with regards to their <span class="elsevierStyleItalic">medicalized</span> desires&#59; in essence&#44; physicians become just a tool for fulfilling their wishes&#46; Finally&#44; there are also socio-political reasons explaining the extension of <span class="elsevierStyleItalic">medicalization&#46;</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> For instance&#44; the transition from public health care services to private health care services fits perfectly well with the transition from <span class="elsevierStyleItalic">patients</span> to <span class="elsevierStyleItalic">clients</span>&#44; as new health users have consumer mentalities&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Wish-fulfilling medicine&#58; law of desire</span><p id="par0045" class="elsevierStylePara elsevierViewall">What do people strive for in the 21st Century&#63; High paying jobs&#44; money&#44; time&#44; to look better&#44; to feel comfortable&#44; pleasure&#44; etc&#46; &#40;<a id="intr0015" class="elsevierStyleInterRef" href="http://www.doyletics.com/index10.htm">http&#58;&#47;&#47;www&#46;doyletics&#46;com&#47;index10&#46;htm</a>&#41;&#46; Thus&#44; it is not surprising the increasing tendency for medicine to be used to fulfill personal wishes &#40;i&#46;e&#46; better social skills&#44; enhance work performance&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleItalic">Wish-fulfilling medicine</span> can be defined as &#8220;doctors and other health professionals using medical means &#40;medical technology&#44; drugs&#44; etc&#46;&#41; in a medical setting to fulfill the explicitly stated&#44; prima facie non-medical wish of a patient&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In contrast to patients&#44; wish-fulfilling clients choose the treatment they receive from the first consultation&#44; rather than their doctors&#46; Thus&#44; the role of the physician becomes that of a technician&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Buyx</span> defended that fulfilling the wishes of competent people is morally neutral<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#59; however&#44; she rejected the idea of including <span class="elsevierStyleItalic">wish-fulfilling medicine</span> in standard medical care&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and I concur&#46; The problem with <span class="elsevierStyleItalic">wish-fulfilling medicine</span> is that the demand for healthcare is insatiable&#46; This is troublesome particularly in Europe where the welfare states are more and more under pressure&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The development of <span class="elsevierStyleItalic">wish-fulfilling medicine</span>&#44; a term coined by <span class="elsevierStyleItalic">Matthias Kettner</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> is probably a reflection of what is happening in our societies&#46; &#8220;Traditional&#8221; patients&#44; those who <span class="elsevierStyleItalic">sensu stricto</span> have diseases&#44; demand their physicians to restore them to their previous healthy state&#46; On the other hand&#44; &#8220;new&#8221; clients come to their physicians demanding solutions for problems that are not considered diseases &#40;e&#46;g&#46; baldness&#41;&#46; Unfortunately&#44; the problem here is that it is not an easy task to delineate the definition of disease that can evolve and change with regard to different socio-cultural contexts&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In this context&#44; there are an increasing number of health issues that could be included within the concept of <span class="elsevierStyleItalic">wish-fulfilling medicine</span>&#46; Reproductive medicine or plastic surgery are two classic examples of <span class="elsevierStyleItalic">wish-fulfilling medicine</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> For instance&#44; more than half of the genetic pre-implantation diagnoses in the U&#46;S&#46; are not motivated by therapeutic issues but by gender selection &#40;<a id="intr0020" class="elsevierStyleInterRef" href="http://elpais.com/diario/2009/08/16/sociedad/1250373604_850215.html">http&#58;&#47;&#47;elpais&#46;com&#47;diario&#47;2009&#47;08&#47;16&#47;sociedad&#47;1250373604&#95;850215&#46;html</a>&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Disease mongering&#58; gas lighting&#63;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The concept of <span class="elsevierStyleItalic">disease mongering</span> was first defined by <span class="elsevierStyleItalic">Lynn Payer</span> in the 90s and refers to the attempts made by pharmaceutical companies to artificially enlarge the &#8220;market&#8221; by convincing people that they suffer from some sickness and need medical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Since pharmaceutical companies are under constant pressure to maintain sales growth&#44; the temptation to expand the range of &#8220;diseases&#8221; treatable by a present commercialized product via marketing may be too strong&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Typical examples of <span class="elsevierStyleItalic">disease mongering</span> are social anxiety disorder&#44; low bone mineral density&#44; restless legs&#44; premature ejaculation&#44; and female sexual dysfunction&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Psychiatry is one of the medical disciplines more vulnerable to <span class="elsevierStyleItalic">disease mongering</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> specifically because Psychiatry lacks objective data &#40;i&#46;e&#46; biomarkers&#41; for diagnosing disorders&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Disease mongering</span> is nowadays more frequent because we are living in the Internet era&#46; This means that &#8220;we have access to more information and more quickly than ever before in human history&#8221;&#44; and Internet sites are the way people develop social networks&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In other words&#44; it is easier than ever to create novel diseases and to disseminate information on them&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> News media are key in the dissemination of these new diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> For example&#44; the emergence of the Internet may help to explain why fibromyalgia&#44; a clinical entity that was recognized in the 1990s by the <span class="elsevierStyleItalic">American College of Rheumatology</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and apparently suffered by 2&#8211;3&#37; of the general population&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> did not previously create a huge social alarm&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="par0075" class="elsevierStylePara elsevierViewall">There has been a Copernican change in the concept of health since the post-world war II WHO definition of health&#46; <span class="elsevierStyleItalic">Wish-fulfilling medicine</span> is usually placed within private practise&#44; but the limits between &#8220;traditional&#8221; medicine and <span class="elsevierStyleItalic">wish-fulfilling medicine</span> are not always clear&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> This is particularly worrying nowadays&#44; given that some <span class="elsevierStyleItalic">Public Health Services</span> could be on the brink of collapse&#44; as they &#8220;navigate&#8221; between the scarce resources available and the users&#8217; insatiable health demands&#46; Therefore&#44; it appears there is a necessity to generate clear-cut <span class="elsevierStyleItalic">Public Health Services Port-folios</span> placing <span class="elsevierStyleItalic">wish-fulfilling medicine</span> within the limits of private practise&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It appears as if we were going toward <span class="elsevierStyleItalic">a brave new world</span>&#46; However&#44; it is important to erase any kind of fatalism&#58; the process of <span class="elsevierStyleItalic">medicalization</span> is by no means stationary and can be challenged&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Modern western societies are characterized&#44; among others&#44; by the satiety of senses and the lack of frustration&#46; We thought that this vacuous superabundance would make us happier&#46; But this has not been true&#46; Desire&#44; like <span class="elsevierStyleItalic">Eros</span>&#44; appears to be insatiable&#46; Instead&#44; boredom is our punishment&#46; It is possible that <span class="elsevierStyleItalic">Zygmunt Bauman</span> was right&#58; in the inherent nature of desire is written its self-destruction&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">Dr&#46; Blasco-Fontecilla has received lecture fees from Eli Lilly&#44; Shire&#44; and AB-Biotics in the last three years&#46;</p></span></span>"
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          "titulo" => "Wish-fulfilling medicine&#58; law of desire"
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          "titulo" => "Disease mongering&#58; gas lighting&#63;"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Western societies are characterized by a growing medicalization of life events&#44; such as pregnancy&#44; aging&#44; or even death&#46; Three concepts -medicalization&#44; wish-fulfilling medicine&#44; and disease mongering- are key in understanding the current practise of Medicine&#46; Quite surprisingly&#44; not a single study has addressed the relationship between all three of these concepts&#46; The term medicalization expanded under the open-ended concept of health developed by the World Health Organization in 1946&#46; One of the consequences of medicalization is the transition from patients to clients&#46; Physicians are under increasing pressure to meet the insatiable demands of their clients&#46; The term wish-fulfilling medicine refers to the increasing tendency of medicine to be used to fulfill personal wishes &#40;i&#46;e&#46; enhanced work performance&#41;&#46; The insatiable demand for healthcare is troublesome&#44; particularly in Europe&#44; where the welfare states are more and more under pressure&#46; Finally&#44; the term disease mongering refers to attempts by pharmaceutical companies to artificially enlarge their &#8220;markets&#8221; by convincing people that they suffer from some sickness and thus need medical treatment&#46; Typical examples of disease mongering are social anxiety disorder&#44; low bone mineral density&#44; and premature ejaculation&#46; Currently&#44; some Public Health Services could be on the brink of collapse as they &#8220;navigate&#8221; between the scarce resources available and the users&#8217; insatiable health demands&#46; Therefore&#44; it appears necessary to generate clear-cut Public Health Services Port-folios&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las sociedades occidentales se caracterizan por una creciente medicalizaci&#243;n de la vida cotidiana &#40;p&#46; ej&#46;&#44; embarazo&#44; envejecimiento y muerte&#41;&#46; Tres conceptos &#8211;medicalizaci&#243;n&#44; medicina del deseo e invenci&#243;n de enfermedades&#8211; son fundamentales para entender la pr&#225;ctica actual de la Medicina&#46; Resulta sorprendente que la relaci&#243;n entre los 3 t&#233;rminos apenas haya recibido atenci&#243;n en la comunidad cient&#237;fica&#46; El t&#233;rmino <span class="elsevierStyleItalic">medicalizaci&#243;n</span> se expandi&#243; bajo el paraguas del concepto de salud ilimitado desarrollado por la Organizaci&#243;n Mundial de la Salud en 1946&#46; Una de las consecuencias de la medicalizaci&#243;n es la transici&#243;n de pacientes hacia clientes&#46; Los m&#233;dicos est&#225;n cada vez bajo una mayor presi&#243;n por parte de las insaciables demandas de salud de sus clientes&#46; El t&#233;rmino <span class="elsevierStyleItalic">medicina del deseo</span> hace referencia precisamente a la tendencia creciente a usar la Medicina para satisfacer los deseos personales &#40;p&#46; ej&#46; aumento del rendimiento laboral&#41;&#46; Esta insaciable demanda de salud es problem&#225;tica&#44; particularmente en Europa&#44; donde los Sistemas de Salud P&#250;blicos est&#225;n bajo una presi&#243;n creciente&#46; Finalmente&#44; el t&#233;rmino &#171;invenci&#243;n de enfermedades&#187; se refiere a los intentos de la industria farmac&#233;utica para aumentar de manera artificial sus &#171;mercados&#187; al convencer a la gente &#40;clientes&#41; que sufren una enfermedad &#40;previamente inexistente&#41;&#44; para la cual necesitan un tratamiento&#46; Algunos ejemplos de este &#250;ltimo t&#233;rmino son la fobia social o la eyaculaci&#243;n precoz&#46; En la actualidad&#44; algunos Servicios P&#250;blicos de Salud podr&#237;an estar cerca del colapso econ&#243;mico derivado de unos recursos cada vez m&#225;s escasos y una demanda &#40;deseos&#41; de salud cada vez m&#225;s insaciable&#46; Por lo tanto&#44; parece necesaria la creaci&#243;n de carteras de salud claramente definidas en aquellos pa&#237;ses con Sistemas de Salud P&#250;blicos&#46;</p>"
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Humanities in Medicine
Medicalization, wish-fulfilling medicine, and disease mongering: Toward a brave new world?
Medicalización, medicina del deseo e invención de enfermedades: ¿hacia un mundo feliz?
H. Blasco-Fontecilla
Child & Adolescent Psychiatrist, Villalba Mental Health Center, IIS-Puerta de Hierro Hospital, CIBERSAM, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">&#8220;&#91;&#8230;&#93; He remained obstinately gloomy the whole afternoon&#59; wouldn&#8217;t talk to Lenina&#39;s friends &#40;of whom they met dozens in the ice-cream soma bar between the wrestling bouts&#41;&#59; and in spite of his misery absolutely refused to take the half-gramme raspberry sundae which she pressed upon him&#46; &#8220;I&#8217;d rather be myself&#44;&#8221; he said&#46; &#8220;Myself and nasty&#46; Not somebody else&#44; however jolly&#46;&#8221;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Brave new world- <span class="elsevierStyleItalic">Aldoux Huxley</span></span><p id="par0010" class="elsevierStylePara elsevierViewall">The limits of current Medicine are becoming more and more blurred as increasingly more advances are made&#46; Our focus begins to shift from what can we treat to what should we do treat as doctors&#46; Aldous Huxley&#44; a seminal author of the 20th Century&#44; predicted the <span class="elsevierStyleItalic">medicalization</span> of life events&#46; For instance&#44; unhappiness is nowadays treated with antidepressants&#46; We could speculate about which is our <span class="elsevierStyleItalic">soma</span> &#40;the ideal pleasure drug taken by everybody in Aldous Huxley&#8217; famous novel <span class="elsevierStyleItalic">Brave New World</span>&#41; nowadays&#44; but we do not need to look far&#58; the prescription of antidepressants has tripled from 1994 to 2003 in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Two atypical antipsychotics&#44; aripiprazol &#40;Abilify&#174;&#44; Otsuka&#44; Bristol-Myers Squibb&#41; and quetiapine &#40;Seroquel&#174;&#44; AstraZeneca&#41;&#44; and one antidepressant &#40;Duloxetine&#44; Cymbalta&#174;&#44; Eli Lillly&#41; are among the ten best selling prescription drugs in the U&#46;S&#46; &#40;<a id="intr0005" class="elsevierStyleInterRef" href="http://www.businessinsider.com/10-best-selling-blockbuster-drugs-2012-6%3Fop=1">http&#58;&#47;&#47;www&#46;businessinsider&#46;com&#47;10-best-selling-blockbuster-drugs-2012-6&#63;op&#61;1</a>&#41;&#46; This might lead one to think that massive <span class="elsevierStyleItalic">soma</span>-medication of the population has already occurred&#46; Has the <span class="elsevierStyleItalic">medicalization</span> of everyday problems gone too far&#63;</p><p id="par0015" class="elsevierStylePara elsevierViewall">People are using novel medications in dangerous ways&#59; for example&#44; some adolescents use cognitive enhancers to improve cognitive function and some have even died in the aftermath of Viagra<span class="elsevierStyleSup">&#174;</span> use&#46; On the other hand&#44; the pharmaceutical industry is very interested in developing <span class="elsevierStyleItalic">mood brighteners</span> or <span class="elsevierStyleItalic">happiness pills</span> to meet increasing demands&#46; And the lack of a prescription is hardly a problem anymore because you can easily get what you want at a modest price delivered to your door thanks to the Internet&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this context&#44; it is complicated to understand current <span class="elsevierStyleItalic">Medicine</span> without using three concepts&#58; <span class="elsevierStyleItalic">medicalization</span>&#44; <span class="elsevierStyleItalic">wish-fulfilling Medicine</span>&#44; and <span class="elsevierStyleItalic">disease mongering</span>&#46; Quite surprisingly&#44; there are no previous studies addressing the relationship among all three concepts&#46; The concept of <span class="elsevierStyleItalic">medicalization</span> gained importance in the seventies&#44; and it can still be considered a classical term in Sociology and Medicine&#46; In the eighties&#44; researchers began to speak about <span class="elsevierStyleItalic">wish-fulfilling medicine</span>&#46; Lastly&#44; the first article on <span class="elsevierStyleItalic">disease mongering</span> indexed in the PUBMED was published in 2002&#46; Could this latest interest on disease mongering reflect the preoccupation of researchers on the type of medically controlled societies we are creating&#63; Are we headed toward <span class="elsevierStyleItalic">a brave new world</span>&#63;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Medicalization&#58; from patients to clients</span><p id="par0025" class="elsevierStylePara elsevierViewall">Western societies are characterized by a growing <span class="elsevierStyleItalic">medicalization</span> of life events such as puberty&#44; menopause&#44; pregnancy&#44; aging&#44; or even death&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The term <span class="elsevierStyleItalic">medicalization</span> refers to problems previously regarded as normal or as a deviance of normal that are now regarded as &#8220;pathologized&#8221; life events&#44; such as menopause&#44; baldness&#44; or marital separation&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Specifically&#44; <span class="elsevierStyleItalic">medicalization</span> can be defined as &#8220;a process by which nonmedical problems become defined and treated as medical problems&#44; usually in terms of illnesses or disorders&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although it is difficult to establish when this term entered the social and medical vocabulary&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> its use expanded under the open-ended concept of health developed by the WHO in 1946 that stated that &#8220;Health is a state of complete physical&#44; mental and social well-being and not merely the absence of disease or infirmity&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This supposed a Copernican change&#44; as the traditional concept of health&#44; based on the presence&#47;absence of illness -the medical science behind the traditional medical model has evolved through five stages&#58; &#40;1&#41; symptoms&#44; &#40;2&#41; syndromes&#44; &#40;3&#41; tissue alterations&#44; &#40;4&#41; demonstration of the causes behind these tissues alterations&#44; and &#40;5&#41; treatment&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> was replaced by &#8220;a state of complete physical&#44; mental and social well-being&#8221;&#46; In other words&#44; <span class="elsevierStyleItalic">happiness</span>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">One of the areas where <span class="elsevierStyleItalic">medicalization</span> is clearly represented is <span class="elsevierStyleItalic">aging</span> and <span class="elsevierStyleItalic">death</span>&#46; Life expectancy at birth is growing worldwide&#44; particularly in industrialized countries&#46; Even though it is still currently impossible to change our genetic code in order to live longer&#44; we are not far from this possibility&#46; For instance&#44; modification of the daf2 gene can double the life span of worms&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The possibility of extrapolating these advances to human beings has raised serious ethical concerns&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> But&#44; not everyone concerns&#46; The American futurist Ray Kurweil has paid for his cryopreservation along with more than 800 millionaires just in case these advances are not in the foreseeable future &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://elpais.com/diario/2008/08/28/revistaverano/1219940508_850215.html">http&#58;&#47;&#47;elpais&#46;com&#47;diario&#47;2008&#47;08&#47;28&#47;revistaverano&#47;1219940508&#95;850215&#46;html</a>&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Medicalization</span> is also rooted in the field of mental disorders&#46; For instance&#44; individuals lacking personal resources to face certain life events &#40;i&#46;e&#46; marital discord&#41; are displacing the &#8220;usual&#8221; psychiatric patients &#40;i&#46;e&#46; those with schizophrenia&#41;&#46; Indeed&#44; adaptive disorders are the most frequent disorders in public mental health centers in the <span class="elsevierStyleItalic">Community of Madrid</span> &#40;Spain&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Another example is the <span class="elsevierStyleItalic">medicalization</span> of deviances&#44; such as&#44; hyperactivity and learning disabilities&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleItalic">Conrad</span> stressed that there were no hyperactive children in the People&#39;s Republic of China in the seventies whereas ten years later hyperactivity became the most prevalent diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Some of the forces behind <span class="elsevierStyleItalic">medicalization</span> are pharmaceutical companies economic interests&#44; but they do not stand-alone&#46; Physicians are being increasingly pressured by the insatiable demands of their patients &#40;or users&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Indeed&#44; one of the consequences of <span class="elsevierStyleItalic">medicalization</span> is the transition from patients to <span class="elsevierStyleItalic">clients &#40;users&#41;</span>&#46; Clients are more pro-active in making decisions with regards to their <span class="elsevierStyleItalic">medicalized</span> desires&#59; in essence&#44; physicians become just a tool for fulfilling their wishes&#46; Finally&#44; there are also socio-political reasons explaining the extension of <span class="elsevierStyleItalic">medicalization&#46;</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> For instance&#44; the transition from public health care services to private health care services fits perfectly well with the transition from <span class="elsevierStyleItalic">patients</span> to <span class="elsevierStyleItalic">clients</span>&#44; as new health users have consumer mentalities&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Wish-fulfilling medicine&#58; law of desire</span><p id="par0045" class="elsevierStylePara elsevierViewall">What do people strive for in the 21st Century&#63; High paying jobs&#44; money&#44; time&#44; to look better&#44; to feel comfortable&#44; pleasure&#44; etc&#46; &#40;<a id="intr0015" class="elsevierStyleInterRef" href="http://www.doyletics.com/index10.htm">http&#58;&#47;&#47;www&#46;doyletics&#46;com&#47;index10&#46;htm</a>&#41;&#46; Thus&#44; it is not surprising the increasing tendency for medicine to be used to fulfill personal wishes &#40;i&#46;e&#46; better social skills&#44; enhance work performance&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleItalic">Wish-fulfilling medicine</span> can be defined as &#8220;doctors and other health professionals using medical means &#40;medical technology&#44; drugs&#44; etc&#46;&#41; in a medical setting to fulfill the explicitly stated&#44; prima facie non-medical wish of a patient&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In contrast to patients&#44; wish-fulfilling clients choose the treatment they receive from the first consultation&#44; rather than their doctors&#46; Thus&#44; the role of the physician becomes that of a technician&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Buyx</span> defended that fulfilling the wishes of competent people is morally neutral<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#59; however&#44; she rejected the idea of including <span class="elsevierStyleItalic">wish-fulfilling medicine</span> in standard medical care&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and I concur&#46; The problem with <span class="elsevierStyleItalic">wish-fulfilling medicine</span> is that the demand for healthcare is insatiable&#46; This is troublesome particularly in Europe where the welfare states are more and more under pressure&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The development of <span class="elsevierStyleItalic">wish-fulfilling medicine</span>&#44; a term coined by <span class="elsevierStyleItalic">Matthias Kettner</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> is probably a reflection of what is happening in our societies&#46; &#8220;Traditional&#8221; patients&#44; those who <span class="elsevierStyleItalic">sensu stricto</span> have diseases&#44; demand their physicians to restore them to their previous healthy state&#46; On the other hand&#44; &#8220;new&#8221; clients come to their physicians demanding solutions for problems that are not considered diseases &#40;e&#46;g&#46; baldness&#41;&#46; Unfortunately&#44; the problem here is that it is not an easy task to delineate the definition of disease that can evolve and change with regard to different socio-cultural contexts&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In this context&#44; there are an increasing number of health issues that could be included within the concept of <span class="elsevierStyleItalic">wish-fulfilling medicine</span>&#46; Reproductive medicine or plastic surgery are two classic examples of <span class="elsevierStyleItalic">wish-fulfilling medicine</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> For instance&#44; more than half of the genetic pre-implantation diagnoses in the U&#46;S&#46; are not motivated by therapeutic issues but by gender selection &#40;<a id="intr0020" class="elsevierStyleInterRef" href="http://elpais.com/diario/2009/08/16/sociedad/1250373604_850215.html">http&#58;&#47;&#47;elpais&#46;com&#47;diario&#47;2009&#47;08&#47;16&#47;sociedad&#47;1250373604&#95;850215&#46;html</a>&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Disease mongering&#58; gas lighting&#63;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The concept of <span class="elsevierStyleItalic">disease mongering</span> was first defined by <span class="elsevierStyleItalic">Lynn Payer</span> in the 90s and refers to the attempts made by pharmaceutical companies to artificially enlarge the &#8220;market&#8221; by convincing people that they suffer from some sickness and need medical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Since pharmaceutical companies are under constant pressure to maintain sales growth&#44; the temptation to expand the range of &#8220;diseases&#8221; treatable by a present commercialized product via marketing may be too strong&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Typical examples of <span class="elsevierStyleItalic">disease mongering</span> are social anxiety disorder&#44; low bone mineral density&#44; restless legs&#44; premature ejaculation&#44; and female sexual dysfunction&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Psychiatry is one of the medical disciplines more vulnerable to <span class="elsevierStyleItalic">disease mongering</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> specifically because Psychiatry lacks objective data &#40;i&#46;e&#46; biomarkers&#41; for diagnosing disorders&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Disease mongering</span> is nowadays more frequent because we are living in the Internet era&#46; This means that &#8220;we have access to more information and more quickly than ever before in human history&#8221;&#44; and Internet sites are the way people develop social networks&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In other words&#44; it is easier than ever to create novel diseases and to disseminate information on them&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> News media are key in the dissemination of these new diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> For example&#44; the emergence of the Internet may help to explain why fibromyalgia&#44; a clinical entity that was recognized in the 1990s by the <span class="elsevierStyleItalic">American College of Rheumatology</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and apparently suffered by 2&#8211;3&#37; of the general population&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> did not previously create a huge social alarm&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="par0075" class="elsevierStylePara elsevierViewall">There has been a Copernican change in the concept of health since the post-world war II WHO definition of health&#46; <span class="elsevierStyleItalic">Wish-fulfilling medicine</span> is usually placed within private practise&#44; but the limits between &#8220;traditional&#8221; medicine and <span class="elsevierStyleItalic">wish-fulfilling medicine</span> are not always clear&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> This is particularly worrying nowadays&#44; given that some <span class="elsevierStyleItalic">Public Health Services</span> could be on the brink of collapse&#44; as they &#8220;navigate&#8221; between the scarce resources available and the users&#8217; insatiable health demands&#46; Therefore&#44; it appears there is a necessity to generate clear-cut <span class="elsevierStyleItalic">Public Health Services Port-folios</span> placing <span class="elsevierStyleItalic">wish-fulfilling medicine</span> within the limits of private practise&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It appears as if we were going toward <span class="elsevierStyleItalic">a brave new world</span>&#46; However&#44; it is important to erase any kind of fatalism&#58; the process of <span class="elsevierStyleItalic">medicalization</span> is by no means stationary and can be challenged&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Modern western societies are characterized&#44; among others&#44; by the satiety of senses and the lack of frustration&#46; We thought that this vacuous superabundance would make us happier&#46; But this has not been true&#46; Desire&#44; like <span class="elsevierStyleItalic">Eros</span>&#44; appears to be insatiable&#46; Instead&#44; boredom is our punishment&#46; It is possible that <span class="elsevierStyleItalic">Zygmunt Bauman</span> was right&#58; in the inherent nature of desire is written its self-destruction&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">Dr&#46; Blasco-Fontecilla has received lecture fees from Eli Lilly&#44; Shire&#44; and AB-Biotics in the last three years&#46;</p></span></span>"
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          "titulo" => "Brave new world- Aldoux Huxley"
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          "titulo" => "Disease mongering&#58; gas lighting&#63;"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Western societies are characterized by a growing medicalization of life events&#44; such as pregnancy&#44; aging&#44; or even death&#46; Three concepts -medicalization&#44; wish-fulfilling medicine&#44; and disease mongering- are key in understanding the current practise of Medicine&#46; Quite surprisingly&#44; not a single study has addressed the relationship between all three of these concepts&#46; The term medicalization expanded under the open-ended concept of health developed by the World Health Organization in 1946&#46; One of the consequences of medicalization is the transition from patients to clients&#46; Physicians are under increasing pressure to meet the insatiable demands of their clients&#46; The term wish-fulfilling medicine refers to the increasing tendency of medicine to be used to fulfill personal wishes &#40;i&#46;e&#46; enhanced work performance&#41;&#46; The insatiable demand for healthcare is troublesome&#44; particularly in Europe&#44; where the welfare states are more and more under pressure&#46; Finally&#44; the term disease mongering refers to attempts by pharmaceutical companies to artificially enlarge their &#8220;markets&#8221; by convincing people that they suffer from some sickness and thus need medical treatment&#46; Typical examples of disease mongering are social anxiety disorder&#44; low bone mineral density&#44; and premature ejaculation&#46; Currently&#44; some Public Health Services could be on the brink of collapse as they &#8220;navigate&#8221; between the scarce resources available and the users&#8217; insatiable health demands&#46; Therefore&#44; it appears necessary to generate clear-cut Public Health Services Port-folios&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las sociedades occidentales se caracterizan por una creciente medicalizaci&#243;n de la vida cotidiana &#40;p&#46; ej&#46;&#44; embarazo&#44; envejecimiento y muerte&#41;&#46; Tres conceptos &#8211;medicalizaci&#243;n&#44; medicina del deseo e invenci&#243;n de enfermedades&#8211; son fundamentales para entender la pr&#225;ctica actual de la Medicina&#46; Resulta sorprendente que la relaci&#243;n entre los 3 t&#233;rminos apenas haya recibido atenci&#243;n en la comunidad cient&#237;fica&#46; El t&#233;rmino <span class="elsevierStyleItalic">medicalizaci&#243;n</span> se expandi&#243; bajo el paraguas del concepto de salud ilimitado desarrollado por la Organizaci&#243;n Mundial de la Salud en 1946&#46; Una de las consecuencias de la medicalizaci&#243;n es la transici&#243;n de pacientes hacia clientes&#46; Los m&#233;dicos est&#225;n cada vez bajo una mayor presi&#243;n por parte de las insaciables demandas de salud de sus clientes&#46; El t&#233;rmino <span class="elsevierStyleItalic">medicina del deseo</span> hace referencia precisamente a la tendencia creciente a usar la Medicina para satisfacer los deseos personales &#40;p&#46; ej&#46; aumento del rendimiento laboral&#41;&#46; Esta insaciable demanda de salud es problem&#225;tica&#44; particularmente en Europa&#44; donde los Sistemas de Salud P&#250;blicos est&#225;n bajo una presi&#243;n creciente&#46; Finalmente&#44; el t&#233;rmino &#171;invenci&#243;n de enfermedades&#187; se refiere a los intentos de la industria farmac&#233;utica para aumentar de manera artificial sus &#171;mercados&#187; al convencer a la gente &#40;clientes&#41; que sufren una enfermedad &#40;previamente inexistente&#41;&#44; para la cual necesitan un tratamiento&#46; Algunos ejemplos de este &#250;ltimo t&#233;rmino son la fobia social o la eyaculaci&#243;n precoz&#46; En la actualidad&#44; algunos Servicios P&#250;blicos de Salud podr&#237;an estar cerca del colapso econ&#243;mico derivado de unos recursos cada vez m&#225;s escasos y una demanda &#40;deseos&#41; de salud cada vez m&#225;s insaciable&#46; Por lo tanto&#44; parece necesaria la creaci&#243;n de carteras de salud claramente definidas en aquellos pa&#237;ses con Sistemas de Salud P&#250;blicos&#46;</p>"
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