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Stedman’s Online Medical Dictionary defines disease as an interruption, cessation, or disorder of body function, system, or organ; or a morbid entity characterized usually by at least two of these criteria: recognized etiologic agent(s), identifiable group of signs and symptoms, or consistent anatomic alterations. The International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) is one of the main texts used in the United States to identify, categorize, and diagnose disease. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), is used to define and diagnosis mental disorders. While these sources are used in common medical practice, it is not completely clear in the philosophy of science what truly defines the diseases and disorders that these texts classify. Some have argued that there is not a simple definition of disease. Within the philosophy of medicine and bioethics, there is not only disagreement about what a disease is but whether or not disease can be defined or whether it is necessary to have a fixed definition in order to provide care.
Naturalism and Nominilism
A simplistic yet prevailing conception of what disease is can be viewed from the lens of “naturalism” or “nominilism.” Viewed from a naturalistic point of view, disease is a real thing that can be quantified, observed, or described using the language of natural science. To the naturalist, a disease can be discovered in nature, is not invented by social convention, and is not dependent on contextual circumstance. The true naturalist views disease as value free and objective. Disease from a naturalist point of view, according to the philosopher Christopher Boorse, causes interruptions in the ability to “perform typical physiological functioning with at least typical efficiency” (Kovacs 1998, p. 31). This point of view, however, has been critiqued because “typical physiology” and “typical efficiency” cannot be objectively described, nor are they value-free terms (i.e., what is meant by “typical”?).
The nominalist point, on the other hand, views disease not as something essential in nature but rather as a description of socially constructed conditions. As stated by Lester King in 1954, the point of view that “disease is the aggregate of those conditions, which, judged by the prevailing culture, are deemed painful, or disabling, and which, at the same time, deviate from either the statistical norm or from some idealized status” would fit within this nominalist point of view (King 1954, p. 197). Historically a purely naturalistic view of disease as a germ or lesion has given way to a view of disease that appeals more to a nominilist point of view. Ailments that fall within modern medical health care, such as depression or hypertension, challenge a naturalistic point of view because these conditions appeal to socially defined criteria by which one would be in need of professional care or qualify for some sort of intervention.
Disease, Illness, Sickness, and Health
In discussing the concept of disease, attention has been brought to how terms such as disease, illness, or sickness relate. Oftentimes these concepts have been used interchangeably. However, philosophers argue that separating the concepts may be useful. Disease is distinguished from illness in that disease is the subject matter of the medical practitioner and scientific medicine. Illness, on the other hand, explains what the person is experiencing. Sickness is what is attributed by society to individuals who conceive of themselves as ill and whom medical professions identify as having a disease. Each of these concepts justifies action. Medical professionals are charged with identifying disease, discovering diseases, and treating persons with such conditions. Persons who are ill are charged with describing the subjective experience of their condition to others who may be able to help. Society is responsible for determining the rights and duties of a person who is ill and/or diseased. Thus conceptualizing disease as separate from illness and sickness can be useful in bringing into perspective the varying roles of the medical practitioner, the individual, and society when negative bodily conditions or states occur.
The concept of disease is also often discussed as it relates to health. That is, to understand what disease is, one must know what health is. The common language conception of health is simply the absence of disease or the negation of being at ease (i.e., dis-ease). A person who is healthy does not have a disease, and a person with a disease is not healthy. However, this simplistic model may not be applicable in all circumstances. For example, a person diagnosed with hypochondriasis certainly is suffering, but the individual does not have any general medical condition that can account for his or her feeling of illness. There are also instances when one feels healthy but may have a serious condition that places the individual at risk for a disease (e.g., a person with hypercholesterolemia or obesity may develop coronary artery disease).
The holistic approach extends the more simple approach to defining health not just as the absence of disease but as a state of complete physical, mental, and social well-being. The holistic model has been adopted and promoted by the World Health Organization. The holistic model would imply that one could meet the condition of not having a specific disease but still may not be healthy. Within the holistic model, eliminating disease from the body is not primary, but rather, health is primary. However, some have argued that a holistic program of health care with the goal of insuring complete physical, mental, and social well-being is not feasible; especially in developing countries, where there are limited resources available for the provision of care.
The model most familiar to Western medicine is the medical model of disease. The medical model suggests that disease is not just absence of health (as defined by the simplified model), but disease can be identified by some set of standard methods, such as a medical examination, laboratory tests, or correspondence with a set of symptoms. Thus within the medical model a person could potentially not have an identified pathophysiological disease but could still be labeled as having a disease as a result of having a set of symptoms and being deemed not healthy through the process of a medical examination.
Controversies in Defining Conditions as Disease
Within modern medicine there are many controversies over what conditions can be properly defined as diseases. One such debate in the general medicine and public health has to do with whether or not obesity can be labeled a disease. George A. Bray, an internationally recognized researcher in the area of obesity and diabetes, has argued that obesity meets the criteria to be labeled a disease. However, other researchers have argued that caution should be taken when labeling obesity as a disease as it may not be appropriate to put it on par with other more serious life-threatening conditions. Those that argue obesity should not be considered a disease suggest that there are no real signs or symptoms of obesity apart from excess adiposity. However, this is circular because excess adiposity is the definition of obesity. Also, while obesity does cause impairment in functioning for some people, there are many people who are obese who have no diminished impairment in functioning. Those who argue that obesity is a disease equate it with other diseases, such as depression. Bray states that obesity involves “deranged neural circuitry responding inappropriately to a toxic environment” (Bray 2004, p. 34).
Another long-standing debate in the medical discipline of psychiatry is whether or not certain psychological conditions can be labeled a disease. A mainstream view of modern practice in psychiatry is that certain psychological conditions rise to the level of an illness when there is a clinically relevant disruption in functioning and distress. The DMS-IV distinguishes a mental pathological condition from a milder form by establishing clinically significant criterion. As stated in the DSM-IV, the condition must cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning” (DSM-IV 1994, p. 7). The determination of significance is a clinical judgment made through the process of a clinical interview with the patient and sometimes with third parties, such as a patient’s family. Further, a mental disorder is often distinguished from a condition that arises as a direct physiological consequence of a general medical condition. For example, disorientation or hallucinations due to a brain tumor or stroke would not be considered a psychiatric condition.
Notably the explanation of aberrant behaviors or mental conditions has changed over the centuries. In past centuries aberrant behaviors and mental disorders were explained as the result of “spirits” or “sins.” With the birth of psychoanalysis, mental conditions were explained as primarily resulting from poor child rearing or the inability of an individual to meet developmental milestones marking social and moral development. However, early twenty-first-century psychiatric practice tends to explain many psychiatric conditions as the result of disruptions in neural circuitry in the brain resulting from a combination of genetic and environmental determinates.
This change in perception of psychiatric conditions is argued to be due to an increasing scientific knowledge about potential causes and treatments. However, the psychiatrist Thomas Szasz has been a prominent critic of this traditional point of view. Szasz argues that mental disorders, as mainstream psychiatry has conceptualized, are not diseases of the brain and that it is inappropriate to call abnormal behaviors and psychological states “diseases.” A crux of difference between these two points of view has to do with the way disease is defined—that is, as a “lesion” of the body or as a social construction or metaphor.
Social Dynamics of Disease and Health Inequalities
Regardless of how disease is defined, it is widely recognized that the spread of disease and the preponderance of health are linked to social factors. For instance, density and frequency of contact among individuals can influence disease outbreak. Dense social contact in urban environments may lead to a rapid spread of certain infectious diseases. Understanding the social networks and dynamics of these environments is a key strategy for developing targeted vaccinations and treatments.
Disease and health are also influenced by social and economic conditions in society. For example, in the early twenty-first century in the United States, Type 2 diabetes mellitus is more common among African American men than their Caucasian counterparts. However, a 2007 study by Margaret Humphreys and colleagues found rates of diabetes among African American men living circa 1900 to be much lower than Caucasian men at that time. Studies looking at coronary heart disease patterns have also reported prevalence shifts whereby the risk of the disease was historically more prevalent in higher socioeconomic classes and now is more prevalent in lower socioeconomic classes (Kunst et al., 1999; Marmot, Adelstein, Robinson, and Rose, 1978; Rose and Marmot, 1981). These studies highlight the fact that disease patterns as well as the social distribution of risk factors for disease can vary by type of disease, time period, and geographic region.
As disease and health are viewed as socially determined, the search for social conditions that gives rise to diseases has become a growing part of medical and public health science. Medical practice in the past centuries was focused primarily on identifying pathophysiological and biological roots for disease and had largely ignored the social contributions to disease. Correspondingly treatments and interventions for disease management have been one-to-one efforts. However, a growing awareness that societal-level phenomena play a large role in health and disease has prompted the medical community to explore some of the broader social and economic forces that influence disease and risk. As such the approach to disease management is also shifting from primarily individual-level one-to-one efforts to include environmental and policy-level interventions designed to address health.
Finding a clear definition of disease and health is not purely a philosophical matter. Conditions that carry the label of disease have practical and political implications. Society responds by directing resources, and individuals with a certain disease are relinquished from certain social responsibilities. However, what counts as disease is often difficult to determine. In some cases it might appear that a certain condition has pathophysiological roots and causes (e.g., germ or lesion) that can be discovered and treated. However, it may be discovered that there are broader social and economic conditions that allow for certain pathophysiological conditions to arise. What then is the disease? Is it the germ or the social condition? The answer that society provides becomes one of the defining features by which health care resources are allocated.
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