The Nature of Disease

Lawrie Reznek

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000579413
• Edition: 1
• Topic: Philosophy
• Subtopic: Social Philosophy

Originally published in 1987, this book is about the classification of bodily conditions into diseases. It provides a full account of the concept of disease, examining the issue of whether disease status is something we discover or invent and the issue of whether disease attributions involve implicit value judgements. It investigates whether bodily conditions fall into natural kinds and whether these debates can be settled by discovering whether there are any natural boundaries dividing conditions into diseases and non-diseases. It considers whether the notion of disease is an evaluative notion or whether judgements about disease status are purely descriptive. The issue of whether other cultures with different values are justified in making different disease judgements is also discussed.

CHAPTER 1 INVENTION OR DISCOVERY?

From anti-psychiatry to anti-medicine

Thomas Szasz is an American psychiatrist who created a revolution in thought with his The Myth of Mental Illness. This started a movement that became known as Anti-psychiatry, so-called because he argued that psychiatrists do not discover the diseases they treat, but invent them. He writes:

When a person does something bad, like shoot the president, it is immediately assumed that he might be mad, madness being thought of as a ‘disease’ that might somehow ‘explain’ why he did it. When a person does something good, like discover a cure for a hitherto incurable disease, no similar assumption is made. I submit that no further evidence is needed to show that ‘mental illness’ is not the name of a biological condition whose nature awaits to be elucidated, but is the name of a concept whose purpose is to obscure the obvious (Szasz, 1973a, p.91).

The obvious is, of course, the procuration of social control of those behaviours (like the shooting of presidents) that we do not like. He writes:

Psychiatric pioneers invent new diseases and formulate new theories of the etiology of these diseases to justify calling certain preexisting social interventions ‘treatments’. Kraepelin invented dementia praecox, and Bleuler invented schizophrenia, to justify calling psychiatric imprisonment ‘mental hospitalization’ and regarding it as a form of medical treatment; having new diseases on their hands, they attributed them to as yet undetected defects of the brain (Szasz, 1976, p.38).

Such an important claim - the claim that all psychiatrists are frauds - demands examination. However, in order to claim that mental illness does not exist, Szasz must show that our concept of disease cannot admit such a category. He writes:

Disease means bodily disease. Gould’s Medical Dictionary defines disease as a disturbance of an organ or a part of the body. The mind (whatever it is) is not an organ or part of the body. Hence, it cannot be diseased in the same sense as the body can. When we speak of mental illness, then, we speak metaphorically. When metaphor is mistaken for reality and is used for social purposes, then we have the making of myth. The concepts of mental health and mental illness are mythological concepts, used strategically to advance some social interests and to retard others (Szasz, 1973a, p.97).

Thus Szasz argues that because ‘patients’ with ‘mental illness’ do not have any underlying physical abnormality, they are not diseased.

The whole anti-psychiatry movement, then, is based on a particular account of the concept of disease. In order to assess the claims of anti-psychiatry, we need to do some philosophy: we need to give a clear account of the concept of disease, and see whether it is indeed necessarily the case that nothing is a disease unless it has an underlying physical abnormality.

But it has not only been psychiatry that has come under fire. Ivan Illich has attacked (physical) medicine itself, arguing that it invents physical diseases too. He believes medicine is guilty of what I will call ‘Conceptual Iatrogenesis’ - the invention of disease. He claims:

All disease is a socially created reality. ... In every society the classification of disease - the nosology - mirrors social organization. ... ‘Learning disability’, ‘hyperkinesis’, or ‘minimal brain dysfunction’ explains to parents why the children do not learn, serving as an alibi for school’s intolerance or incompetence; high blood pressure serves as an alibi for mounting stress, degenerative disease for degenerating social organization (Illich, 1976, pp. 172-4).

The claims of Ivan Illich against physical medicine turn on his claim that medicine invents diseases rather than discovers them. In order to assess the claim, we need to know just what a disease is, and when a disease is genuine. That is, we need to possess a clear account of the concept of disease. In order to assess these charges against medicine and psychiatry, we need to have a philosophic understanding of the concept of disease.

Values and classification

The history of medicine abounds with examples which seem to show that cultural values influence the way we classify bodily (and mental) conditions. The question arises whether values correctly influence what conditions we classify as diseases, or whether they simply bias our perception of the value-free facts. This question reduces to the question whether the concept of disease is a normative or value-laden notion, or whether it is a purely descriptive or value-free concept. If the concept is a normative one, it ought to express the values of the classifiers, and hence differing cultural values should generate different disease classifications (called nosologies). On the other hand, if the concept of disease is a purely descriptive notion, what conditions are recognized as diseases ought not to be influenced by the values of the classifier.

The debate whether the concept of disease is value-laden I will call the Naturalist-Normativist debate. Normativists are those who believe that the concept of disease is a normative or value-laden notion, and Naturalists are those who believe that the concept of disease is a purely descriptive or value-free notion. One of the aims of this book will be to settle this debate.

Settling this debate has important consequences too. If nosologies simply reflect the values of the classifier, we will not be able to criticize other cultures’ classifications for getting things wrong. On this view calling something a disease would be much like calling something a weed. There simply is no value-free fact of weediness that enables us to settle the debate whether Michaelmas daisies are weeds, and so there would be no value-free fact enabling us to settle the debate whether Russian dissidents are ill. Hence, we could not justly criticize Russian psychiatry for making a factual mistake. Whether we can criticize them depends on whether we can show that the concept of disease is not value-laden.

It might seem that our concept of disease is obviously value-laden. This is because many historical examples illustrate that cultural values have influenced the classification of conditions as diseases. The Victorians frowned upon excessive sexual activity. Because of this, excessive seminal loss was viewed as a symptom of the disease which was known as ‘spermatorrhoea’. Dr Curling defined this disease in his book A Practical Treatise on the Diseases of the Testis:

The emissions may, however, be more frequent than is consistent with health, and too readily excited, so much so, indeed, as to affect virility, and to give rise to constitutional symptoms of a serious character. These excessive spermatic discharges constitute the complaint termed spermatorrhoea (Curling, 1856, p.386).

The loss could be voluntary, as in intercourse or masturbation, or involuntary as in nocturnal emissions. The French specialist, Dr Lallemand, described spermatorrhoea as a ‘disease that degrades man, poisons the happiness of his best days, and ravages society’ (Lallemand, 1947, p.ii). No doubt it was the culture’s horror of sexuality that made them see spermatorrhoea at the root of many cases of fatigue, parched skin, loss of hair, stammering, deafness, blindness, and so on.

Masturbation was especially abhorred, no doubt also because of the culture’s values, and was seen as producing grave long-term physical and psychological sequelae. Henry Maudsley describes the consequences of masturbation begun early in life as follows:

We have degenerate beings produced who as regards moral character are very much what eunuchs are represented to be - cunning, deceitful, liars, selfish, in fact, morally insane; while their physical and intellectual vigour is further damaged by the exhausting vice (Maudsley, 1868, p. 156).

In the same sexually repressive nineteenth century, the childhood expression of any sexual interest was seen as pathological. Dr William Acton invented the disease of ‘sexual precocity’ in his treatise The Functions and Disorders of the Reproductive Organs which first appeared in 1857. He wrote:

Amongst the earliest disorders that we notice is sexual precocity. In many instances, either from hereditary predisposition, bad companionship, or other evil influences, sexual feelings become developed at a very early age, and this abnormal excitement is always attended with injurious, often with the most deplorable consequences (Acton, 1857, p.78).

He goes on to recommend ‘the shock of cold water falling on the organs’ as necessary for the treatment of the condition. Here we see the Victorian values towards sexuality influencing the classification of childhood sexual interest as a disease.

Only until recently was homosexuality per se considered a disease. The change in its disease status was brought about by a change in social attitudes - no new fact has been discovered about homosexuality. In the late 1960s Gay Liberation and more militant groups such as the Gay Activists Alliance and the Gay Liberation Front demanded that physicians reclassify the condition of homosexuality. After four years of confrontation, the American Psychiatric Association, influenced by the more tolerant values of the time, voted in 1974 to remove homosexuality per se from the class of diseases. Here again we see prevalent social values influencing the classification of a condition as a disease.

In the antebellum southern states of America, black slaves were described as suffering from certain diseases by Dr Samuel Cartwright’s ‘Report on the diseases and physical peculiarities of the Negro race’ published in the New Orleans Medical and Surgical Journal, 7 May 1851. He describes the disease ‘drapetomania’ - ‘the disease causing slaves to run away’, and ‘dysaesthesia aethiopsis’ - which caused slaves to ‘break, waste and destroy everything they handle - abuse horses and cattle - tear, burn and rend their clothing, and pay no attention to the rights of property’. This illustrates how the values of the white slave-owners influenced their classification of such behaviour. What we would interpret as the healthy protest against an evil system, Dr Samuel Cartwright saw as the manifestation of a disease.

In fact, so influential were these values that the very state of being black was considered to be a disease. Benjamin Rush claimed to have discovered the disease of ‘Negritude’. He claimed to have discovered the disease in 1792 when he came across a case of what he took to be a spontaneous cure. Henry Moss was a Negro slave who had depigmented patches on his skin (he was suffering from the disease of vitiligo). Rush took these to indicate a partial spontaneous cure of the disease all Negroes suffered from. This was the disease of Negritude, a mild form of congenital leprosy whose only symptom was the darkness of the skin.

There is a South American tribe most of whose members suffer from the disease of dyschromic spirochaetosis, an infectious disease that carries considerable morbidity and mortality. However, it is characterized by rose-coloured spots on the skin which the tribe find attractive. So much so, that they consider it unhealthy and abnormal to be without the spots, and those who do not have the infection are excluded from marriage (Dubos, 1965, p.54). Again we see that what a culture finds desirable influences the classification of a condition as a disease.

It appears from these examples that a good case can be constructed for the view that the concept of disease is value-laden, and expresses the values (and prejudices) of the culture using the concept. The best explanation, or so it seems, of the fact that the classification of conditions varies with the values of the culture is that the concept of disease is itself a value-laden notion. Just as we might explain why the classification of plants as weeds varies with different people’s values by pointing out that the concept of weed is a value-laden notion, so we can explain the variation in disease classification.

Normativists can thus explain why divergent cultural values lead to divergent nosologies. Tristram Engelhardt is a Normativist, and he puts his position thus:

Disease does not reflect a natural standard or norm, because nature does nothing - nature does not care for excellence, nor is it concerned for the fate of individuals qua individuals. Health, insofar as it is to indicate anything more than the usual functions or abilities of the members of the species, must involve judgments as to what members of that species should be able to do - that is, must involve our esteeming a particular type of function (Engelhardt, 1976, p.266).

That is, the concept of disease is something that reflects our esteeming or positive evaluation of certain states (those that constitute health).

But, it might be argued, if the concept of disease is a normative and not a purely descriptive one, how do we explain the fact that there is such widespread agreement as to what are and are not diseases? We would expect widespread disagreement about what are diseases amongst cultures that do not share the same values. However, what we find is that there is widespread unanimity. People do not disagree with the judgment that TB, or leprosy, or breast cancer are diseases. This is more compatible, it seems, with the view that the concept of disease is a descriptive notion - cultures not sharing the same values but agreeing on the facts would classify the same conditions as diseases if the concept was purely descriptive.

However, the Normativist can argue that the widespread agreement as to the classsification of conditions as diseases testifies not so much to the fact that the concept of disease is descriptive, but rather to the widespread sharing of certain values. As Peter Sedgwick points out:

Once again, it can be argued that these cultural variations apply only to marginal cases of sickness and health, that there are some physical or mental conditions that are ipso facto symptomatic of illness, whether among Bushmen or Brobdignagians, duchesses or dockworkers. But there is no reason to believe that the “standardized” varieties of human pathology operate according to a different logic from the “cultural dependent” varieties. The existence of common or even universal illnesses testifies, not to the absence of a normative framework for judging pathology, but to the presence of very widespread norms (Sedgwick, 1973, p.35).

Naturalism, on the other hand, explains why there is such a widespread agreement in a different way. If the concept of disease is a descriptive one, then agreement is reached in spite of the difference in values because the concept does not reflect them. Even Tristram Engelhardt remarks:

Even if it should be the case that cultural prejudices play a role in judgments that homosexuality or polydactylia are diseases, it would appear that bronchogenic carcinoma and typhoid fever are unambiguously diseases, apart from any reference to particular cultures or ideologies. There ap...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Dedication Page
• Table of Contents
• Acknowledgments
• Introduction: Medicine and the Need for Philosophy
• Chapter 1: Invention or Discovery?
• Chapter 2: Taxonomic Realism 1: Natural Kinds
• Chapter 3: Taxonomic Realism 2: Semantics
• Chapter 4: The Nature of Disease
• Chapter 5: The Normal and the Pathological
• Chapter 6: The Concept of Function
• Chapter 7: The Naturalist Theory
• Chapter 8: The Concept of Harm
• Chapter 9: The Normativist Theory
• Chapter 10: Disease Entities as Natural Kinds
• Chapter 11: The Semantics of Disease Terms
• Conclusion: When is a Disease not a Disease?
• Bibliography
• Index