Boundaries of Disease: Disease and Risk

Abstract Increasingly, medical care targets conditions, like hypertension and hypercholesterolemia, which are defined as ranges of some clinical variable, not by any concrete physical pathology. These ranges are usually chosen from data on modifiable risk, as well as by other empirical consequences. Such purported disease categories face three main criticisms, one practical and two conceptual. The practical issue is overdiagnosis: the fear that more people suffer harm than benefit from such diagnoses. The second issue is Schwartz’s and Accad’s complaint that disease and risk of disease must not be confused. The third issue is that most of the literature on risk-based diseases wrongly assumes a conceptual connection between disease and medical treatment. In this essay I analyze these issues about risk-based diseases from the viewpoint of my biostatistical analysis of health and disease. I reach no conclusion on the first, the overdiagnosis of specific conditions. But I conclude that the two conceptual criticisms are wholly valid: in traditional medical thought, neither risk nor treatability implies pathologicity. So Pickering was right: current categories of hypertension, high cholesterol, and the like are not true diseases, nor even diagnostic criteria for true diseases. They are, at best, only categories of justified medical treatment.