Introduction
Szasz
claimed mental illness is an expression of ethical disapproval of a behaviour involving
a covert negative moral evaluation (Szasz (1960): 114-115). Examining
psychiatry’s role in the abuse of political prisoners by diagnosing them as having
schizophrenia with ‘reformist delusions’ it was suggested that both physical
and mental disease concepts are evaluative but that the role of values is
greater for mental illness (Fulford et al (1993): 806-807) because values
underlying designation of states as physical disease are said to be more
commonly shared and thus less problematic for physical illness compared to
mental illness (Fulford in Boch & Chodoff (1991): 80-82).
Defining
disease and illness in a biologically based value-free manner still contained
implicit value judgements ((Boorse (1975) & Kendell (1975)). More recent propositions
have dealt with the issue of values in different ways. Wakefield acknowledged
the role of values in judging if a factual dysfunction is harmful and should
qualify as a disorder (Wakefield (1992): 374)). This proposition also relied on
value judgments to decide if there was a supposedly factual value-free
dysfunction present (Murphy & Woolfolk (2000): 245-7). Fulford presented
the argument that it was identifying illness that was crucial based on a
‘failure of doing’ (Fulford (1989)) and that disease was what was associated
with producing illness (Fulford in Bloch & Chodoff (1991): 85). The values
associated with the designation of illness were described as medical values as
opposed to moral or aesthetic values (Fulford (1989): 109)) though to me the
distinction is not clear.
The
aim of this essay is to discuss how commonly values are involved in evaluating
if states are diseases.
How
often do different groups of people agree on the disease status of problems?
A
survey in Finland of a randomly selected representative sample of 3000
laypeople, 1500 doctors, 1500 nurses and all 200 MPs asked the respondents
about 60 relevant states (chosen by expert consensus) were asked if they regarded
these states as diseases (Tikkinen et al (2012)) on a Likert scale with
5-points from strongly agree to strongly disagree. The paper’s definition of
disease was not given explicitly but was implied by an additional question - the
state should entitle the affected person to tax-funded healthcare. The states
covered a wide variety of conditions including those commonly thought of as
physical and mental health conditions. Strongly agree and agree answers will be
combined into a single agreement category. Answers for some conditions will be
discussed to highlight the potential role of values in deciding if states are diseases
including discussions if the conditions could be viewed as clear dysfunctions
(Wakefield (1992) or failures of doing (Fulford (1989) or biological
disadvantages (Kendell (1975)).
Doctors
were more likely to regard states as diseases but there were some exceptions –
for example age-related muscle loss was regarded as a disease by 50% of lay
people and MPs and 40% of nurses but just over 20% of doctors. Mental health
conditions were more likely to be regarded as diseases by doctors than other
groups. I will discuss some of the results in further details to discover if
value judgements influenced disagreements as to disease status
Anorexia
nervosa is a severe mental health condition - with high rates of mortality (Chesney
et al (2014)) and in women amenorrhea reducing fertility meeting Kendell’s criteria
of biological disadvantage (Kendell (1975): 310) – was regarded as a disease by
only just over 60% of lay people and MPs but over 90% of doctors and 80% of
nurses. Given the combination of increased mortality, physical complications
and reduced fertility and the markedly different associated thoughts/ behaviour
it is interesting that over a third of lay and MP respondents do not regard anorexia
as a disease (there is higher agreement for depression even though depression’s
mortality is much less than that for anorexia (Chesney et al (2014)). Thinking
about possible reasons for this discrepancy between lay/ MP respondents and
doctors it may be that the general public and MPs may not be fully informed
about anorexia’s high mortality or what people in this state experience in
terms of distress and impaired functioning. Another possibility may be that
anorexia involves a disorder of eating – a disorder of appetite (similar to appetites
in the broad sense – see later discussion of substances and sexual functioning).
In this case it is a restriction not perceived over-indulgence. An additional
possibility is the association with thinness which may be regarded as a
physical feature conveying sexual attractiveness and that in some people
anorexia is regarded as trying to achieve a desirable feature, a form of vanity
that is regarded negatively and undeserving of disease status. In terms of
evolutionary dysfunctions (Wakefield (1992): 383) that may be causing anorexia it is
possible there may be functions to suppress appetite in terms of food shortage
or to adopt body shapes regarded as attractive to potential mates but this does
not explain to me why these functions become so awry to produce the severe
distress of anorexia nervosa and its associated biological disadvantage. In any
case even if these evolutionary functions have become dysfunctional their
nature – of perceived wilful suppression of appetites
when unnecessary to achieve thinness - may be subject of moral judgement as
vanity and not deserving of the exemptions of criticism of such behaviour
conferred by disease status (Boorse (1975): 61) which is a value judgement (Wakefield
(1992): 383-4).
Alcoholism
is regarded as a disease by about 50% of lay people and over 60% of doctors;
drug addiction by about one third of lay people and just under 60% of doctors
and smoking as disease by under 10% of all four groups. Nicotine is a highly
addictive substance so alcoholism, drug addiction and smoking can all be
regarded as forms of addiction caused by a biological substance with biological
effects contributing to addiction. Alcohol problems have been defined as a
clinical syndrome to allow further research into psychobiological causes
(Edwards & Gross (1976)). The concept involves the biological consequences
of alcohol – such as increasing tolerance to its effects and the withdrawal
signs/ symptoms – interacting with psychological phenomenon such as negative
conditioning promoting using the substance to ameliorate unpleasant withdrawals
to create the constellation of increased use with subsequent problems. This has formed the basis of other addiction
syndromes. Tolerance and withdrawal can both viewed as a result of evolutionary
functions (Wakefield (1992): 383) – tolerance is mediated by the body reacting
to increasing exposure to a bioactive compound by increasing its ability to
metabolise the compound and reduce its pharmacodynamic effect on the body; withdrawal
represents what happens when the body is no longer being exposed to this
bioactive compound when it may have reduced production of its own compounds
that have similar effects and/or reduced sensitivity of systems to this
compound’s effects. These bodily responses can be seen as evolutionary
functions to maintain homeostasis. Psychological mechanisms – such as
conditioning- can be viewed similarly as evolutionary functions to increase an
organism’s adaptation to its micro-environment. Therefore addiction to a
biological substance inducing tolerance and withdrawal could be seen to involve
dysfunction and therefore achieve part of the criteria for disease status (Wakefield
(1992): 383).Smoking, alcoholism and drug addiction are associated with increased
mortality though smoking to a lesser extent than severe forms of alcoholism and
drug addiction (Chesney et al (2014)) and could be seen as biological
disadvantages conferring disease status (Kendell (1975): 310).
Both
smoking and alcohol are legal as are some drugs that can be addictive for
certain purposes (e.g. opioids for pain relief). Smoking, even with passive
smoking, may be regarded as less harmful to other people than alcoholism and
drug addiction with their associations with crime, aggressiveness and other
antisocial behaviours. The marked difference for smoking compared to
alcohol/drugs may reflect a reluctance to confer disease status on smokers for
several possible reasons: unwillingness to medicalise a much more prevalent
group than alcoholism or drug addiction or that people are not ‘sold’ on a
disease model of addiction that applies logically to smoking. Doctors have
similar rates for regarding alcoholism and drug addiction as diseases but lay
people are less likely to confer disease status on drug addiction than
alcoholism – this may reflect an unwillingness to confer disease status on drug
addiction (and entitlement to tax funded health care) which may reflect that
they personally disapprove of drug use compared to use of alcohol.
It
seems likely to me that the difference in assigning disease status to these
different addictions represents differences in personal attitudes to the
substances involved in the particular addiction. These different attitudes are
likely to be influenced by personal values. These values may be influenced by
various factors such as experience with their own or others with addiction,
training and education (such as doctors taught the medical model of addiction
as exemplified by the alcohol syndrome), the media, cultural attitudes and so
forth. It may also be that “familiarity breeds contempt” – people have
experience of wanting to use and actually have used cigarettes, alcohol and
illegal drugs. Their personal experience of unproblematic use and desire for these
substances makes it harder for them to see why people should have problematic
use and cannot stop using it to that degree and may impute personal failing as
a reason why people become addicted. The public may be more likely to see drug
addiction as immoral as it involves either illegal substances or legal
substances for limited purposes being abused for pleasure. This appetite for pleasure out of control
seems to attract varying degrees of moral censure and disbarring from disease
status depending on the perception of the substance’s legality or perversion of purpose. Doctors may be
indoctrinated by their training to regard it as a disease. They may also see
people in their clinic with highly problematic use and regard their experience
as different from non-problematic use – it may appear “syndromal” to them or
even if an excess on a dimension with everyday use (“quantity has a quality of
its own”).
Gambling
addiction was regarded as a disease by 25% of lay people, 50% of doctors and
about 40% of MPs and nurses. Gambling addiction as its’ name suggests has
adopted the substance addiction model for problematic gambling behaviours in
the absence of a biological substance. This absence of a biological substance
means that the addiction model relies on dysfunctional psychological functions
(including impulsivity) so may be less likely to meet evolutionary dysfunction
criteria for disease status. To my knowledge there is less evidence for
increased mortality for gambling addiction than the other addictions mentioned
above and it would be hard to demonstrate reduced fertility that was not
socially mediated so is unlikely to meet biological disadvantage disease status
either (Kendell (1975): 310).. Gambling may be regarded as more harmful to
others in the gambler’s social network than smoking due to its financial
effects. In Finland gambling is legal but under a government monopoly (alcohol
was also strictly regulated at the time of the survey). There may be a reluctance, particularly
amongst lay people but also about half of doctors, to regard a problematic
behaviour as a disease in the absence
of a biological substance causing an effect on the brain leading to tolerance
and withdrawal effects. This may reflect values indicating reluctance to assign
disease status in the absence of biological causes for a behaviour that is
regarded as an appetitive disturbance
or indulgence. Gambling may be regarded as an immoral indulgence not deserving of disease status.
Erectile
dysfunction is regarded as a disease by less than 50% of all groups. Erectile
dysfunction presumably reduces chances of reproduction thus meeting Kendell’s biological
disadvantage criteria for a disease (Kendell (1975):
310). The
dysfunction of erectile function would meet criteria for a failure of doing -
of difficulty in performing penetration (Fulford (1989)) and a dysfunction in
the sense of having difficulty in its’ evolutionary function of penetration
(Wakefield (1992):310). Despite this, less than half of respondents regard it
as a disease which makes little sense according to me especially as doctors are
likely to view states as diseases (Tikkinen et al, 2012). Possible reasons
could include that it is often regarded as a psychological problem caused by
anxiety and that as such is regarded a nervous problem not a disease. This
ignores it is often associated with medical conditions such as diabetes or as a
medication/ surgical side-effect or can be caused directly by disease processes
such as vascular disease and is coded in ICD10 both as a mental and a
urological disorder. Another possibility could be that it is a state that
affects sexual functioning it is
regarded as an appetitive problem, a
dysfunction of sexual enjoyment/ activity that may influence people’s value
judgement of it. This may lead them to viewing this state not as a disease
entitled to tax funded healthcare but a problem of lifestyle or desired state
(the desire linked to activities either regarded as base or immoral).
There
is inconsistency around the allocation of disease status to adult-onset
diabetes (over 80% all groups), elevated blood pressure (70% or more in all
groups) and elevated cholesterol (about 50-60% in all groups). These conditions
are all aspects of metabolic syndrome and share many features such as a complex
aetiology involving multiple genes of small effect (often shared between these
different conditions) interacting with environmental factors such as exercise,
diet and alcohol intake. Given these are different aspects of a broader
condition why the difference in rates of according disease status to them? They
share many common factors with an evolutionary function – blood pressure to
circulate blood and maintain renal function, cholesterol and glucose metabolism
to provide immediate energy whilst also storing energy and providing building
blocks to produce important molecules such as steroids. The dysfunction element
arises from the consequences of these functions (at high levels of blood
pressure for instance) to lead to a variety of processes, for example atheroma,
with several adverse consequences like cardiovascular disease (Wakefield (1992):310). The resultant increased
mortality would meet biological disadvantage criteria for disease (Kendell (1975): 310). It may be that the lower rates
of elevated cholesterol being regarded as a disease is because of its closer
association with diet in people’s minds and specifically overeating of sinful foods like cream cakes and
English breakfasts that is it attracts negative moral judgements affecting
people’s willingness to accord it disease status.
Finally,
few considered dental caries a disease (about 30-40%) except over 60% of
doctors despite being a clear disease with resultant pain and even loss of
teeth indicating dysfunction (Wakefield (1992):310) but perhaps not increased
mortality/ reduced fertility of biological disadvantage (Kendell (1975): 310).
The association of dental caries with indulgently
eating sweets and chocolates may induce negative moral judgements or views
about not restricting appetites.
How
do moral judgements affect decisions about disease status?
It is
important to note that this survey asked different groups of people (the
public, doctors, nurses, MPs) whether states should be conceived as diseases
and entitled to tax funded health care but their opinion could be wrong (Wakefield
(1992): 377). These different groups are likely to have had different levels of
knowledge of the different conditions and under the pressure of completing the
survey their thinking processes in deciding whether to allocate disease status
may have been different than if they had time to research the condition and
form reasoned judgments.
The
allocation of disease status to various conditions is often to my mind
illogical. Hypertension, type 2 diabetes and elevated cholesterol are similar
conditions yet elevated cholesterol is less likely to be regarded as disease.
Erectile dysfunction is often not regarded as a disease despite often being a
result of pathological processes and medication effects. Nicotine addiction
despite involving a highly addictive substance is rarely considered a disease.
Alcohol addiction is more likely to be considered a disease than drug
addiction. Dental caries is often not considered a disease.
The
reasons why conditions which seem to have legitimate claims to disease are
disregarded as such seems to rely on value judgements about their perceived
nature. Anorexia may not be regarded as a disease – despite its high mortality
for a mental health condition and a diagnostic biomarker which is rare for
mental health conditions – because it is a disorder of eating, an appetite, and possibly because it may be
regarded as a form of vanity with its association with thinness.
The
association of cholesterol with eating and in particular eating foods regarded
as sinful (high fat foods) may
explain why elevated cholesterol is less likely to be regarded as a disease
than type 2 diabetes and hypertension. It may be more likely to regarded as a
moral failing – not restricting oneself from eating badly, a poorly regulated appetite.
If one
regards all addiction to a biological substance – whatever the substance – as a
similar phenomenon the varying answers about disease status of alcohol, drugs
and nicotine are confusing. The different answers for alcohol and drugs may
reflect greater moral disapproval on
the use of drugs as compared to alcohol and subsequent reluctance to extend
disease status and tax-funded help to people with drug addiction problems. For
nicotine another value judgment may apply – since smoking is so common so
everyday there may be a value judgement that ubiquitous phenomenon should not
be regarded as diseases and especially if involve pleasure-seeking activities with smoking as a vice. In gambling addiction
the link to vice and pleasure seeking is more obvious in the absence of a
biological substance.
All
these conditions described do not have associated differences of structure/
anatomy or physiological causative processes or mechanisms. Addiction may have
induced nerve receptor changes as a result of the biological addiction but this
is as a result of the substances involved not a cause of the problems. Yet even
where seem obvious differences in structure or physiological process and
biological disadvantages such as erectile dysfunction a minority regard it as
disease possibly because it’s a dysfunction of a sexual activity and hence linked to appetite and morality.
Turning
to what may be described as mental illness what are the relevant points? The
frequent absence of biomarkers and differences in structure/ processes leading
to the clinical features can weaken the claim to disease status especially if the value issues outlined
later casts further doubt. Of course one can point out that these differences
in structure/ process only counts as a disease marker AFTER we have already
decided that the condition is a disease (Fulford (1989). If a biological
difference in structure or process was found in all people with the condition
that explained its clinical features many would accept that as ‘proof’ of
disease status yet biology is not the sole hurdle for what is described as
mental illness achieving disease status. These judgement as to whether a
condition is a disease if it involves behaviour
regarded as immoral or even if involves appetites or drives will involve mental
illnesses more than physical illness as behaviour is more frequently an
associated or central component of mental illness.
Many
impulse control or ‘addiction’ type problems or conditions involving sexual
desires involve an additional value judgement as to whether this is best viewed
as an immoral behaviour not worthy of the excuses and exemptions of a disease
(Boorse (1975): 61). The person judging may reflect that if the person is
taking illegal drugs why should they be given the exemption of criticism of
behaviour that disease status confers (Boorse (1975):
61) for something they view as morally wrong. Imagine the discomfort and clash with
personal values that would arise from trying to describe paedophilia as a
disease? Even if a biological difference in structure or process was discovered
that was likely to be causative of paedophilia the moral revulsion that
paedophilia evokes would make people reluctant to see it as a disease.
The
inconsistencies in allocating disease status to the different states in the
survey suggests that moral judgements are integral to the decisions made. There
may also be a folk version of stoic beliefs that temperate and mild
affectations are unhealthy but excessive appetites (and by implication)
over-denial is mentally unhealthy ((Nordenfelt (1997)). Disease status entitling tax-funded healthcare
is likely to mean that moral judgements of deserving
help and support are involved. Moral judgements of the type that somebody has
contributed to their problem in a blameworthy manner -by not denying appetites
or immoral behaviour – is undeserving of
such help and associated excuses (Boorse (1975): 61). In these cases, a
negative moral judgement is an obstacle to being allocated disease status but
this happens less often in doctors decision-making as they are more likely to
recognise states as diseases (Tikkinen et al (1975)). The reasons for this could
be multiple and more than one reason may operate in each doctor.
Doctors
·
are
taught about states in the same medical/ disease paradigm so may be more likely
to not distinguish between diseases and non-diseases.
·
may
wish to extend their claim to professional expertise and thus generate work for
themselves by allocating disease status even when it is not warranted
·
may
possess vague concepts of what disease is and allocate disease status
haphazardly
·
may
see patients presenting with problems caused by these states and wish to help
and by allocating disease status helps justify medical help being given
·
experience
and knowledge of these states may allow them to put less weight on moral
judgements and focus on other factors relevant to disease status.
In
contrast to the above discussion, negative
moral judgments may increase the chance of behavioural states being
allocated mental disease status. Schizophrenia
may be readily conceived as disease despite the attempts to emphasise
continuity between psychosis and typical human experience/ behaviour to reduce
stigma whilst ignoring the evidence for discontinuity (David (2010)) because this
continuity view induces uncomfortable feelings (Thibodeau & Peterson, 2018).
A view of schizophrenia as a disease and separate from health may help resolve
this uncomfortable feeling. Black slaves were viewed as trying to deprive their masters of
their labour may be viewed as immoral by white American doctors and facilitated
viewing them as suffering drapetomania (Wakefield (1992): 373-4). Perhaps
Soviet dissidents were viewed by their psychiatrists as decadent for trying to
oppose the proletarian dictatorship which then led to their views described as
‘reformist delusions’ and need for treatment (Fulford et al (1993): 806-807)).
These negative moral judgements leading to disease status allocation may be
enhanced when the consequences are negative such as confinement and unpleasant/
unnecessary treatments. To prove this would require careful questioning of the
people making the judgements whether this statement is true. It may be that
different doctors – with different training or cultures of value judgements –
would be less likely to regard these states as diseases. Pre-civil war US black
doctors for instance may be less likely to have regarded black slaves escaping
white masters as immoral or bad and thus less likely to view them as mentally
diseased.
Conclusion
Value
judgments around morality and appetites are involved when people judge whether
states are regarded as diseases. Examples where what seem clear diseases are
commonly not regarded (especially by the public) as diseases include dental
caries and erectile dysfunction. This suggests value judgements around morality
and appetites can trump what appear to be factual dysfunctions/ biological
disadvantage. Since the value judgements
are of behaviours these value judgments are more likely to be found in mental
illness than in physical illness. Value judgments that reduce the chances of
states being regarded as disease include if it involves behaviours regarded as
immoral or if it involves appetites/ drives and disease status leads to favourable consequences
such as tax funded healthcare to help. If the consequences of disease status
are negative (such as confinement) then negative value judgements may make it
more likely for states to be regarded as diseases. There seems to be
disagreement between individuals as to whether value judgments prevent
allocation of disease status to states. Different groups and individuals may
place different weights on these value judgments. Doctors for a variety of
reasons may be more likely to regard states as diseases.
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