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.
Armando Henrique Norman, Charles Dalcanale Tesser
