Gentle Medicine Could Radically Transform Medical Practice

This is a licensed re-published article by: Aeon - Jacob Stegenga is a Professor at NTU Singapore. He has published widely in the philosophy of science and philosophy of medicine. He is the author of Medical Nihilism, described as ‘a landmark work’, Care and Cure: An Introduction to Philosophy of Medicine, and a book to be published in 2026 titled Heart of Science. Edited by Sam Haselby.

The Current State of Medical Science

Numerous criticisms of medical science have emerged in recent years. Some critics argue that spurious disease categories are being invented. Others say here that the benefits of most new drugs are minimal and often exaggerated by clinical research. The harms of these drugs are frequently underestimated. Additionally, some point to flaws in the research methods themselves. They argue that methods once seen as gold standards—like randomized trials and meta-analyses—are now malleable. These methods have been bent to serve industry interests rather than patient needs.

In 2015, the chief editor of The Lancet medical journal summarized60696-1/fulltext) these criticisms succinctly:

Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.

Structural Issues in Medicine

These problems arise from a few structural features of medicine. A prominent one is the profit incentive. The pharmaceutical industry is highly profitable. The financial gains from selling drugs create incentives for questionable practices. Another significant feature is the hope and expectation of patients that medicine can help them. Physicians are trained to intervene actively, whether by screening, prescribing, referring, or performing surgery. Lastly, the complex causal basis of many diseases complicates effective interventions. For example, taking antibiotics for a simple bacterial infection is straightforward. However, taking antidepressants for depression is entirely different.

In my book Medical Nihilism (2018), I synthesized these arguments to conclude that the current state of medicine is indeed in disrepair.

Introducing Gentle Medicine

How should medicine confront these challenges? I coined the term ‘gentle medicine’ to describe a range of changes that could be enacted to help address these issues. Some aspects of gentle medicine involve minor modifications to routine practices and policies, while others could be more substantial.

Clinical Practice Revisions

Let’s begin with clinical practice. Physicians could adopt a less interventionist approach. Many physicians and surgeons are already conservative in their therapeutic methods. My suggestion is that this therapeutic conservatism should become more widespread. Additionally, patient hopes and expectations should be carefully managed. As the Canadian physician William Osler (1849-1919) advised, “One of the first duties of the physician is to educate the masses not to take medicine.” Treatment should generally be less aggressive and more gentle when feasible.

Rethinking the Medical Research Agenda

Another aspect of gentle medicine involves how the medical research agenda is determined. Most research resources in medicine belong to the industry. Its profit motive contributes to an “obsession for pursuing fashionable trends of dubious importance.”

We need more experimental antibiotics in the research pipeline. High-quality evidence about the effectiveness of various lifestyle factors in modulating depression would also be beneficial. Furthermore, developing a malaria vaccine and treatments for neglected tropical diseases is crucial, given their massive disease burden. The current coronavirus pandemic has highlighted our lack of understanding about fundamental questions, such as the transmission dynamics of viruses and the impact of masks on disease transmission. Unfortunately, there is little profit to be made from pursuing these research programs. Instead, substantial profits can be generated by developing ‘me-too’ drugs—new versions of existing medications that offer little additional benefit.

Policy-Level Changes

A policy-level change that some advocate is to reduce or eliminate the intellectual property protection of medical interventions. This would mitigate the financial incentives that seem to corrupt medical science. It could also lead to cheaper new drugs. The antics of individuals like Martin Shkreli would be impossible under such a system. However, would this also result in less innovative medical research and development? This argument is often raised to defend intellectual property laws, but it has serious flaws.

The history of science shows that major revolutions often occur without such incentives. Think of Nicolaus Copernicus, Isaac Newton, Charles Darwin, and Albert Einstein. Breakthroughs in medicine are no different. The most significant advancements—like antibiotics, insulin, and the polio vaccine—were developed in contexts that differ greatly from today’s pharmaceutical profit-driven environment. These breakthroughs were radically effective, unlike many current blockbuster drugs.

Another policy-level change would involve separating the testing of new pharmaceuticals from those who profit from their sale. Several commentators have argued for this independence. It could raise the evidential standards we apply to medical interventions, allowing us to better understand their true benefits and harms.

The Need for Evidence on Gentle Medicine

Returning to the research agenda, we also need more rigorous evidence about gentle medicine itself. We have extensive evidence regarding the benefits and harms of initiating therapy. However, we lack rigorous evidence about the effects of terminating therapy. Since part of gentle medicine advocates for a more conservative therapeutic approach, we should gather more evidence about the effects of drug discontinuation.

For instance, in 2010, researchers in Israel applied a drug discontinuation program to a group of elderly patients taking an average of 7.7 medications. By strictly following treatment protocols, the researchers withdrew an average of 4.4 medications per patient. Only six drugs (2 percent) were re-administered due to symptom recurrence. No harms were observed during the drug discontinuations, and 88 percent of the patients reported feeling healthier. We need much more evidence like this, and of higher quality (randomized, blinded).

The Challenges of Gentle Medicine

Gentle medicine doesn’t equate to easy medicine. We might discover that regular exercise and healthy diets are more effective than many pharmaceuticals for various diseases. However, maintaining a healthy lifestyle is not easy. Perhaps the most crucial health-preserving intervention during the current coronavirus pandemic is ‘social distancing.’ This measure is entirely non-medical, as it doesn’t involve medical professionals or treatments. Yet, social distancing requires significant personal and social costs.

In summary, gentle medicine suggests changes to clinical practice, the medical research agenda, and policies regarding regulation and intellectual property. By adopting these principles, we can move toward a more sustainable and effective healthcare system that benefits pets, people, and the planet.

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