Academic journal article Independent Review

Defining Disease: The Gold Standard of Disease versus the Fiat Standard of Diagnosis

Academic journal article Independent Review

Defining Disease: The Gold Standard of Disease versus the Fiat Standard of Diagnosis

Article excerpt

Illness and healing are as old as civilization. For millennia, the shaman or priest aided persons suffering from all manner of human adversities, only some of which we now regard as diseases. Distinguishing between sin and sickness, between faith healing and medical treatment was a slow historical process, still incomplete in the minds and lives of millions. The scientific-materialist approach to medical healing--a western European idea--is less than two hundred years old.

Traditionally, the physician was a private entrepreneur. In the United States, only in the twentieth century did the federal and state governments begin to regulate and restrict the sale of medicines and the practice of medicine. After the end of World War II (earlier in the Soviet Union), the distribution of medical services throughout the developed world was transformed from a capitalist to a socialist system: the source of the physician's income shifted from the patient to the government or a government-regulated insurance system. At the same time, more and more personal habits and problems--from smoking to obesity to the management of unruly children--became defined as diseases, and more and more drugs were removed from the free market and made available only by prescription and only to persons diagnosed as ill. In a few centuries, Western societies were transformed flora theocracies to democracies and then to pharmacracies (Szasz [2001] 2003).

What should and what should not count as a disease? This question is a troublesome one for all of medicine, especially for psychiatry. Everyone--doctors and patients, drug companies and heath insurance systems, politicians and people--has a stake in how we demarcate disease from nondisease. None of us can escape the obligation to grapple with this issue and to decide how and where we ought to draw the line. For physicians and the medical profession, the question requires two different answers--one to satisfy the needs of medical science, another to satisfy the needs of medical practice and the persons it serves.

Medical science, a part of natural science, is concerned with the empirical investigation of a part of the material world--the human body--by means of precisely defined and rigorously applied concepts and techniques. Medical practice, though based on science and the use of scientific technology, is not a science; it is a type of human service, the content and delivery of which are shaped by economic, ideological, religious, and political interests, in the delivery of medical care, insistence on scientific precision and rigor is condemned as rigidity and lack of compassion.

The conflict between the need for precision and rigor in practicing science and the need for flexibility and compassion in providing medical care is reflected in our current nosology--a mixture of precisely identified natural phenomena and imprecisely defined economic, ideological, political, and social judgments and occurrences. As a result, this classification system is an intellectual embarrassment and an invitation to political-economic mischief. Extricating ourselves from the dilemmas of contemporary health-care policy and politics requires that we acknowledge the need for two (of more) systems of defining and classifying diseases.

Science is synonymous with materialism, with the study of facts, with how things are. It is axiomatic that there can be no scientific investigation or scientific theory of nonmaterial "entities" and moral concepts, such as angel and devil, spirit and mind, virtue and vice. To say that is not to say that those things "do not exist." They "exist," but they are not a part of the material world. Their study entails inquiry into and reasoning about not facts, but beliefs (explanations), experiences (how things feel), values (good and bad), and social policies (what actions in what circumstances ought to be considered licit and illicit).

All this is commonplace. …

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