Expanding disease and undermining the ethos of medicine

Abstract

The expansion of the concept of disease poses problems for epidemiology. Certainly, new diseases are discovered and more people are treated earlier and better. However, the historically unprecedented expansion is criticised for going too far. Overdiagnosis, overtreatment, and medicalization are some of the challenges heatedly debated in medicine, media, and in health policy making. How are we to analyse and handle the vast expansion of disease? Where can we draw the line between warranted and unwarranted expansion? To address this issue, which has wide implications for epidemiology, we need to understand how disease is expanded. This article identifies six ways that our conception of disease is expanded: by increased knowledge (epistemic), making more phenomena count as disease (ontological), doing more (pragmatic), defining more (conceptual), and by encompassing the bad (ethic) and the ugly (aesthetic). Expanding the subject matter of medicine extends its realm and power, but also its responsibility. It makes medicine accountable for ever more of human potential dis-eases. At the same time it blurs the borders and undermines the demarcation of medicine. Six specific advices can guide our action clarifying the subject matter of medicine in general and epidemiology in particular. To avoid unlimited responsibility and to keep medicine on par with its end, we need to direct the expansion of disease to what effectively identifies or reduces human suffering. Otherwise we will deplete medicine and undermine the greatest asset in health care: trust.

Journalists’ views on media coverage of medical tests and overdiagnosis: a qualitative study

“…Advances in early detection testing through diagnostic technology, screening programmes, biomarkers, artificial intelligence and self-tracking technologies such as the Apple Watch are increasingly aimed at healthy people to detect a potential disease prior to the onset of symptoms. [1][2][3][4][5] While early detection tests may have benefits for those with a potentially serious disease, there is considerable evidence that unnecessary testing can harm healthy people through overdiagnosis. [6][7][8] Overdiagnosis occurs when individuals are labelled with a technically correct diagnosis that does not improve health outcomes.…”

Nosology expansion: not always for health’s sake

“…Nosology expansion occurs either by (1) adding newly occurring diseases with distinctive characteristics (e.g. emerging infectious disease like Zika Virus Infections or the Coronaviruses and Acute Respiratory Syndromes) [2] or (2) splitting an existing disease into finer categories (in fashionable language, into "finer granularity") or (3) annexing to a known disease some manifestations, including precursors, previously unknown or known but regarded as outside the disease boundaries.…”

“…In search of an anchor on which to fix the general concept of disease Hofmann [1] rightly emphasizes that alleviating suffering is the ethical central mission of medicine and suffering should be a key element in defining what constitute a disease. However suffering is subjective, and the area where subjectivity plays a large role, mental health and disorders, is just the one where disease delimitation has always been and remains most problematic and often highly controversial, as permanent discussions on the DSM special nosology show [19].…”

How to Draw the Line Between Health and Disease? Start with Suffering

“…What falls under the concept of disease has expanded significantly over the years [ 15 , 30 , 39 , 42 , 60 – 62 , 64 – 66 , 83 ]. While this expansion has enabled helping more people, it has also drawn attention to its negative implication, such as overdiagnosis, overtreatment, and medicalization [ 10 , 44 , 52 , 58 ].…”