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In search of "non-disease"http://bmj.com/cgi/content/full/324/7342/883
Clinical reviewIn search of "non-disease"Richard Smith BMJ, BMA House, London WC1H 9JR The BMJ recently ran a vote on bmj.com to identify the "top 10 non-diseases."1 Some critics thought it an absurd exercise,2 but our primary aim was to illustrate the slipperiness of the notion of disease. We wanted to prompt a debate on what is and what is not a disease and draw attention to the increasing tendency to classify people's problems as diseases.
In 1979 the BMJ published a study that did something similar.3
Non-medical academics, medical academics, general practitioners, and
secondary school students were invited to say whether 38 terms did or
did not refer to a disease. Almost 100% thought that malaria and
tuberculosis were diseases, but less than 20% thought the following
to be diseases: lead poisoning, carbon monoxide poisoning, senility,
hangover, fractured skull, heatstroke, tennis elbow, colour
blindness, malnutrition, barbiturate overdose, drowning, or
starvation (figure). People were split 50:50 over whether hypertension,
acne vulgaris, or gall stones were diseases. The doctors were
more likely to view the terms as referring to diseases. The authors
of this study included Guy Scadding, who spent much of his life
spelling out to doctors that no general agreement exists on how to
define a disease.
Fourteen years earlier, the New England Journal of Medicine had
published a paper arguing the case for "non-diseases."4
Better, argued Clifton Meador, to describe a patient in whom a
diagnosis could not be made as having a "non-disease" rather than
make "the common error of continuing to label such patients with
non-existent diseases." He produced a classification of non-disease
and concluded that "the treatment for non-disease is never the
treatment indicated for the corresponding disease entity. In this
statement lies the ultimate value of the science of non-disease."
Thomas Sydenham (1624-1689) thought that diseases could be classified just like plant and animal species. In other words, diseases have an existence independent of the observer and exist in nature, ready to be "discovered." In complete contrast, others see the notion of disease as essentially a means of social control.5 Doctors define a patient's condition as a "disease" and are then licensed to take various actions, including perhaps incarceration. "Each civilisation," wrote Ivan Illich, "defines its own diseases. What is sickness in one might be chromosomal abnormality, crime, holiness, or sin in another."6 The Oxford Textbook of Medicine wisely stays away from defining a
disease. The Chambers Dictionary defines disease as "an
unhealthy state of body or mind; a disorder, illness or ailment with
distinctive symptoms, caused eg by infection." Neither definition is
operationally helpful, especially as health is even harder to define
than disease. Imre Loeffler, surgeon, essayist, and wit, says that
the World Health Organization's famous definition of health as
"complete physical, psychological, and social wellbeing" is achieved
only at the point of simultaneous orgasm, leaving most of us
unhealthy (and so, by the Chambers Dictionary definition,
diseased) most of the time.
Disease is often defined as a departure from "normal," and helpfully David
Sackett and others offer six definitions of normal in Clinical
Epidemiology, "the bible of evidence based medicine"(table
1).7 One common definition is
that you lie more than two standard deviations from the mean on
whatever measure is used
To have your condition labelled as a disease may bring considerable benefit.
Immediately you are likely to enjoy sympathy rather than blame. You
may be exempted from many commitments, including work. Children learn
very young that saying you have a headache will bring sympathy and a
hug, whereas saying, "I can't be bothered to go to school" will bring
anger and punishment. Having a disease may also entitle you to
benefits such as sick pay, free prescriptions, insurance payments,
and access to facilities denied to healthy people. You may also feel
that you have an explanation for your suffering.
But the diagnosis of a disease may also create many problems. It may allow the authorities to lock you up or invade your body. You may be denied insurance, a mortgage, and employment. You are forever labelled. You are a victim. You are not just a person but an asthmatic, a schizophrenic, a leper, an epileptic. Some diseases carry an inescapable stigma, which may create many more problems than the condition itself. Worst of all, the diagnosis of a disease may lead you to regard yourself as forever flawed and incapable of "rising above" your problem. Consider the case of alcoholism, a hotly disputed diagnosis. Better perhaps to be "an alcoholic" than a morally reprehensible drunk. But is it helpful to think of yourself as "powerless over alcohol," with your problem explained by faults in your genes or body chemistry? It may lead you to a learned and licensed helplessness. Illich puts it like this this6:
We began our search for non-diseases by generating our own definition and list. By "non-disease" we meant "a human process or problem that some have defined as a medical condition but where people may have better outcomes if the problem or process was not defined in that way." This exercise prompted an internal debate about whether we were insulting those who might regard themselves as having what others might classify as a non-disease. We responded by making clear that we were not suggesting that the suffering of people with these "non-diseases" is not genuine. The suffering of many with "non-diseases" may be much greater than those with widely recognised diseases. Consider the suffering that might come from grief, loneliness, or redundancy.
Having generated our own list, we then invited suggestions from our editorial board. We were surprised that we quickly achieved a list of nearly 100. Next, readers were invited to add to the list, boosting it to nearly 200. Paul Glasziou, a general practitioner from Queensland, Australia, and a
member of the BMJ editorial board, has used most of these to
produce an ICND The complete list is interesting, and I was surprised that we could generate so many non-diseases. Some of these non-diseases already appear in official classifications of disease, and perhaps those that do not currently appear will be appearing soon. Disease classifications are likely to grow not shrink, particularly as genetics begins to allow the separation of what are currently single diseases into many. What mattered most about this process, however, was not the list but the
debate. Rapid responses to the debate are summarised on p 913.
Surely, everything is to be gained and nothing lost by raising
consciousness about the slipperiness of the concept of
disease.
Competing interests: None declared.
This article has been cited by other articles:
Rapid Responses:Read all Rapid Responses
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Copyright 2012 by Vaccination News, A Non-Profit Corporation. All Rights Reserved. This content may not be copied unless permission in writing from Sandy Gottstein has been obtained. 
|
 "A foolish faith in authority is the worst enemy of truth." -- Albert Einstein, letter to a friend, 1901 "I know of no safe depository of the ultimate powers of the society but the people themselves, and if we think them not enlightened enough to exercise control with a wholesome discretion, the remedy is not to take it from them, but to inform their discretion by education." -- Thomas Jefferson, letter to William C. Jarvis, September 28, 1820 "What's the point of vaccination if it doesn't protect you from the unvaccinated?" -- Sandy Gottstein "Who gets to decide what the greater good is and how many will be sacrificed to it?" -- Sandy Gottstein |
and
found almost 200 
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What is a
disease? 
The pluses and
minuses...