On Disease Attribution and Medical Legitimacy
In this blogpost I am collecting some of my recent tweets on the topic of attribution of “disease” or “disorder” in medicine and psychiatry, and whether legitimacy of medicine depends on that. I have edited the tweets for clarity. (Also see the post Beyond Definitional Disagreements for additional background.)
Suffering, impairment, harm, neurobiological and psychological differences, these exist independent of anyone’s wishes, but whether we see them through the concept of “disease” is a different issue that can be validly debated without committing a philosophical or scientific error. (link)
There are indeed truths out there, but “disease” is not among those truths. What does exist is suffering, impairment, harm, and various sorts of neurobiological and psychological differences, etc., but our conceptualizations of these phenomena do not constitute fundamental truths. (link)
While characterization of distress/incapacity as “disease” is coherent and historically respectable, it is not obligatory for others to adopt the same definition because this isn’t some objective, natural fact about the world. I think what happens is that people seem to think that calling something a “disease” or denying that it is one justifies whether we can approach it and treat it medically. I think such arguments are fallacious. That justification doesn’t and cannot come from mere disease attribution.
***
The same issues apply in principle across all of medicine, but in paradigmatic cases of disease attribution such as cancer, there is such strong agreement about the presence of bodily changes, the negative consequences, and the need for medical care that “disease” attribution is basically uncontested. (link)
Imagine someone saying, “cancer is not a disease.” What could they mean by this while being factually accurate? Any alternative perspective would have to contend with the facts of uncontrolled cellular proliferation that if left unchecked results in a high chance of death. While we may imagine such alternative perspectives in theory, in practice they are either absent or in extreme minority (Ivan Illich died from cancer, refusing medical treatment on philosophical grounds).
Things are different (in degree, not kind) in the realm of mental health. There is disagreement not only on the nature of bodily changes, psychological differences, negative impact, and the necessity of “medical” care, but there is also more than one game in town when it comes to available perspectives. If someone says “psychosis is not a disease,” they can mean so many different things while remaining true to the facts. They could point to the absence of reliably identifiable biological differences and absence of any consensus on what makes such differences “pathological,” they could point to a variety of ways of understanding psychosis that don’t rely on the concept of “disease” (psychoanalytic, existential, spiritual, enactive, etc.), could point to a variety of non-medical treatments & management approaches, and individual self-understandings.
To clarify: I’m not saying that the concept of “disease” doesn’t apply to psychosis. It is applicable, but it doesn’t have the force, the explanatory power to contain disagreements & to dominate over other perspectives in the way it dominates over others in the case of cancer.
***
Mark Ruffalo: This is interesting to me, Awais. I have thus far assumed that what grants medicine the authority to treat a problem is the “disorderedness” of that problem. This is, in a way, a Szaszian argument, i.e., if mental disorders are not diseases, then medicine should have nothing to do with them. But what you are saying, I think, is that disorderedness does not or should not bear on whether medicine (in this case, psychiatry) has a legitimate claim to treating these problems.
Awais Aftab: I think the problem is that while you reject Szasz's conclusion, you still play by the rules he has set for this debate :) Let's try to unpack the claim that the legitimacy of medicine depends on how we define what a disorder is. How could that be?
How could a definition have so much power that we can legitimize or de-legitimize an entire profession simply by our choice of words? It's a bit like bringing God into existence simply by defining him as existing! Accepting this leads you into a conundrum. If a concept is to provide such a foundation, it needs to be a naturalist one (grounded in facts about the world), but at the same time you want to defend a concept of disease that is "pre-scientific" and decidedly not naturalist.
On one hand you define disorder/disease as “suffering & impairment,” on the other hand you also want to make the claim that “disorderedness” is some natural fact that exists out there in the world. But if you want to believe that suffering and impairment come naturally stamped as disordered or not-disordered, then you need naturalist criteria for “disorderedness” in addition to the presence of suffering & impairment, otherwise the claims are not consistent.
Does disorderedness have a bearing on medicine's legitimacy in treating certain problem? Yes, it has a bearing in the sense that judgments of disorderdness are relevant, but these judgments don't need to be naturalist and the legitimacy is not dependent on them.
Where does the legitimacy come from? It comes from things such as presence of suffering/impairment, medicine's ability to accurately understand the nature of and treat certain instances of suffering safely and effectively, medicine's accountability to science and society, the social and scientific legitimacy of its professional training, etc. Nothing in this requires we rely on the notion of “disorder” or “disease,” let alone that we rely on a notion of “disorder” that requires “disorderedness” to be a natural fact.
***
I don’t think all suffering is mental illness, clearly it’s not. We carve out certain forms of suffering/impairment/harm (and identify their etiologies & investigate treatments) by designating them as “disorders” but this carving out is not naturalistic (not determined by objective, natural facts) but rather this carving out is a value-laden process driven by folk-psychological judgments of abnormality (at least in current clinical practice). Furthermore, medicine’s legitimacy doesn’t depend on how exactly we carve out this space and whether we use a naturalist notion to do so. (link)
Regarding suffering, I don’t mean “distress” narrowly, I mean the variety of ways in which harm can be generated, whether it is personal distress, impairment in functioning, or harm to others. If a condition is not associated with some form of harm or risk of future harm, it is not really captured by our current notions of disorder nor is there any reason for medicine to tackle it as a condition of interest.
I have not maintained any separation between medicine and psychiatry in this regard. There are differences of degree, since psychiatry is comparatively more value laden and there is comparatively more disagreement, more variability, lack of neurobiological dysfunctions, but all medicine is value-laden and the concept of “disease” or “disorder” faces problems of the same kind, whether in medicine or psychiatry.
***
We have to be careful here and distinguish between the question of the nature of the construct(s) being considered and the question of disorder/disease attribution. These are very different questions! Whether disorder attribution is naturalistic or not doesn’t tell us anything about the nature of the construct in question (which could very well be a natural kind or be a discrete identity with single etiology -- COVID-19, e.g. --, or may be highly socially constructed -- hysteria, e.g.) The following figure is something I use in presentations with students is illustrate this point. (link)
