Beyond Definitional Disagreements

This blog post is derived from a twitter thread, in response to this blog by Mark Ruffalo.

I’ve been thinking a lot about how to navigate debates where participants strongly disagree on definitions of concepts such as “disease” and “pathology.” These concepts don’t have a single, privileged definition, so if we are confronted with two internally consistent definitions it seems rather futile in my opinion to insist that one definition must be abandoned in favor of the other. In this scenario, on one hand we have a biological essentialist notion of disease as a demonstrable neurobiological abnormality or lesion, on the other hand we have a notion based on distress and impairment, defended by Ruffalo & Pies. Mark Ruffalo does a good job showing that the prospect of symptoms being “meaningful” does not pose a threat to the internal consistency of the notion of disease as severe distress and impairment. However, the authors of Understanding Psychosis don’t deny that psychosis can be severely distressing and impairing. So, if both sides agree on the relevant facts, i.e., the meaningfulness of psychosis and the presence of severe distress and impairment, where then is the real disagreement? 

The disagreement cannot simply be that one side uses the words “disease” and “pathology” to describe the facts relevant to psychosis & the other side declines to use those words?! So if the disagreement is not merely terminological, what is it about? 

I do think there are factual disagreements but they are subtle, murky and difficult to point out clearly, obscured by the rather superficial “disease vs experience” debate. I suspect a big component of the disagreement lies in the sociocultural narratives surrounding “disease,” and the legitimacy these narratives confer on things such as the professional authority of the physician, the role of medications and other somatic treatments, the power to detain and coerce, and the carte blanche to carry out grand research programmes on biological etiologies. 

I suspect that the discussions tend to get intense because of the perception that the applicability and legitimacy of the medical model rests on whether we call something a “disease”, “disorder,” “illness,” “pathology,” “medical condition.” The critics seem to think that they have administered a coup de grĂ¢ce by denying that psychosis is a disease while the defenders seem to think that they have successfully defended the legitimacy of the medical model by establishing that psychosis is one by their definition. I do think that the applicability and legitimacy of the medical model can be defended (as can the applicability and legitimacy of non-medical models) but I don’t think this legitimacy depends on whether we use this or that definition of disease. 

So I find myself increasingly impatient with definitional debates. Any debate of substance needs to move beyond definitions to an exploration of disagreements of facts and values, something we seem to be increasingly incapable of, devoted as we are to our solipsistic models.