What Counts as Disease?. Rationales and Rationalizations for Treatment.

Abstract

Disease is a fact of nature. Diagnosis is an artefact constructed by human beings. The core concept of disease is a bodily abnormality. Literally, the term 'disease' denotes a demonstrable lesion of cells, tissues, or organs; metaphorically, it may be used to denote any kind of malfunctioning, of individuals, groups, economies. Classic nosology was descriptive, based on somatic pathology. The diagnostician sought to anticipate and approximate the pathologist's findings at autopsy, that is, identify the patients's bodily lesion/disease and its material cause (etiology). For example, the term 'pneumococcal pneumonia' identifies the organ affected, the lungs, and the cause of the illness, infection with the pneumococcus. Contemporary nosology is strategic, based on economic, legal, social, and other interests (unrelated to disease as somatic pathology). The diagnostician seeks to secure reimbursement for medical services, legitimize treatment, justify defining undesirable behavior as disease, and so forth. For example, diagnosis-related groups provide bureaucratic rationale for reimbursing medical services by third-party payers; psychiatric diagnoses provide legal-scientific rationale for treating mental diseases as if they were brain diseases; and so forth. Formerly, diagnoses encoded the objectively verifiable condition of the patient's body (diseases). Today, diagnoses rationalize the health-care policy of the body politic (methods of controlling costs and compensating physicians). We are witnessing the transformation of nosology from the medical-scientific classification of disease as somatic pathology, into the medicalized justification of social policy as 'health care' or 'treatment'.