To survive in today's sharply competitive marketplace, the people who provide health care have begun playing on the very fears and anxieties they are supposed to alleviate.

One hospital ad, for example, shows a woman giving herself a breast exam and declares, "This woman just missed the cancer that will kill her." Another ad features a little boy clinging to his father's pants leg and warns: "Go ahead. Ignore your chest pain. What do you have to lose?"

Such advertising strikes at the heart of Americans' anxiety over health, according to researchers who study medical ethics.

While health-care promotion has been the fastest-growing segment of the marketing industry since the mid-1980s, the trend toward alarmist advertising is relatively new. Advertisers who specialize in the promotion of medical services say marketing that plays on people's fears has become increasingly acceptable nationwide in the last few years.

"It used to be you offered a service, like mammography," said Jerome Reichler, president of Arrco Medical Advertising, which specializes in health-care marketing. "Now the ads say, 'If you don't have a mammogram by age 40, you're at risk of


Reichler and other marketing specialists acknowledge that such ads take advantage of common fears. But they believe such marketing is beneficial because it produces more educated and aware consumers.

"If we do a massive promotion related to breast cancer and encourage women to get mammographies done, everybody wins a situation like that," said James Thalhuber, president of the Academy of Health Services Marketing, a division of the American Marketing Association. "It's great for the institution that conducts the promotion, and it's great for the people that are helped."

To some observers, however, the marketing of health-related fears -- through paid advertising and zealous public relations -- is heightening Americans' already obsessive concern about their health. In conjunction with the constant diet of medical information supplied by the media, they say that health-care marketing is fueling public anxieties and raising unrealistic expectations of what medicine can do.

Medical ethicists say such expectations may eventually boomerang and harm the medical establishment.

"When people realize there are limits to what medicine can do, there is bound to be some disillusionment with the medical establishment," said Arthur Barsky, a Harvard Medical School psychiatrist who has written about the phenomenon. "People are going to be a lot more suspicious of doctors and a lot more disappointed with the outcome of their care."

Such disillusionment, researchers predict, will heighten tensions between health-care providers and their patients and lead to more malpractice suits against doctors and hospitals. Ultimately, it will drive up health-care costs, as Americans insist on access to every conceivable type of health-care service, from organ transplants to infertility procedures to cosmetic surgery.

"People are going to continue to want the services that are being marketed, and they're going to want those services paid for," said Arthur Caplan, a medical ethicist at the University of Minnesota.

Hospitals, health maintenance organizations and clinics first began advertising their services a decade or so ago as a result of increased competition for a relatively static pool of patients.

"Years ago, it used to be that all a hospital had to have was a good, clean, attractive facility with a competent staff and good physicians and you'd have plenty of business," Thalhuber said. "But with the oversupply of providers and changes in reimbursement policy, it has become necessary to compete for business."

Initially, the marketing emphasis was on the quality of care, the competence of the nursing and medical staff, and the services that made the hospital special.

But in recent years as competition has grown stiffer, hospitals have become bolder and more confrontational in their advertising. Consider, for example:

A prize-winning ad promoting the mammography center at Ontario (Calif.) Community Hospital used the threat of death from breast cancer.

Radio commercials in which a group of Boston cosmetic surgeons ask: "Is there anything about your body you don't like?" The implication is that doctors can take care of it, Barsky said.

The ad by Blue Cross/Blue Shield of Massachusetts in a recent Good Health magazine: "One out of four people who read this will be injured this year. (The other three don't think it will be them, either.)"

While individually such promotions may be helpful in educating consumers about specific health risks, when taken together, ethicists say, they cannot help but heighten the public's general anxiety over health.

While the life expectancy of the average American has jumped from 47.3 years in 1900 to 74.7 today, people are more dissatisfied with their health than ever before. One recent national poll found that the proportion of people who are satisfied with their health dropped from 61 percent in the mid-1970s to 55 percent in the mid-1980s.

Although "we are healthier and live longer than ever before, we are feeling worse than ever," said Barsky, who specializes in the treatment of hypochondriacs at Massachusetts General Hospital. "As our standards for good health have risen, we are bothered by aches and discomforts that previously we would have dismissed. Aging itself is now considered a medical problem that can be treated."

While health care marketing may in some cases encourage people to seek preventive care, that too has a double edge.

"Prevention has two sides: one is the obvious value of warding off disease or picking it up early on," said Daniel Callahan, director of the Hastings Center, a New York think tank devoted to medical ethics. "But this emphasis generates a kind of anxiety -- namely, that you may be sick even though you don't know you're sick. The very emphasis on health prevention requires raising the level of anxiety enough so people will feel motivated to go in and get tested."

In recent years, health organizations like the American Cancer Society and American Medical Association have aggressively promoted the benefits of prevention to the general public. While such efforts are generally based on solid scientific data and can be beneficial, ethicists note that many hospitals have jumped on this bandwagon to build up their businesses and create an additional demand for services.

Offering people free cholesterol screening is just one example; it brings people into the hospital or clinic doing the screening, and if a patient's cholesterol levels turn out to be abnormal, the hospital then has a patient to charge for further testing and treatment, which may not be necessary.

"It takes two to tango -- you need patients who are anxious about their health and doctors who have services to sell," said Callahan. "When you put the two together, you have a situation that is bound to drive up health-care costs and keep general expectations escalating."

Callahan believes that this symbiotic relationship is one of the reasons cost-containment measures have largely failed in the last decade.

"It was assumed that if you had a number of hospitals competing for patients, it would bring the costs down," Callahan said. "But it didn't work that way because in order to compete, hospitals spent a lot of money to get the best and latest equipment and to advertise. And they also created a new need for services."

In the end, the ever-widening spotlight on health may just make Americans feel worse.

"People used to expect some measure of suffering as part of their lot in life," Barsky noted. "But if you believe your pain is curable, if not through the wonders of biomedicine, then through your own efforts, then it becomes all the more unbearable when it isn't."