Quaternary prevention: first, do not harm / Prevenção quaternária: primeiro não causar dano / Prevención cuaternaria: primero no hacer daño

ABSTRACT

Clinical prevention, under the influence of public health, has been organised in a chronological manner since the middle of the 20th century. A paradigm shift from a chronological to a constructivist relationship-based preventive pattern of care1 offers new insights into the practice of doctors. This paradigm shift brings to light the concept of quaternary prevention, a critical look at medical activities with an emphasis on the need not to harm. Quaternary prevention addresses the fundamental question of what constitutes too much or too little medicine. It is the fourth form of disease prevention, but also the fourth frame of action for family doctors (Figure 1). The shift from time-based prevention towards a relationship-based organisation offers new perspectives into physicians' work. The physicians observe themselves and question the ethical limits of their activities. In this sense, quaternary prevention is aimed more at the doctor than the patient. Moreover, the four definitions of prevention, published in the Wonca Dictionary of Family Medicine,2 offer a structured way to discuss the activities of family doctors, including ethical considerations on the patient-doctor encounter. Quaternary prevention, also known as P4, is a new term for an old concept first, do not harm. This concept enforces disciplines and attitudes such as evidence-based medicine, quality assurance, defensive medicine, avoiding abusive nosographic diagnoses and ethical issues including those linked to overinformation, and overmedicalisation.3