Two distinguishing characteristics of the health care sphere are complexity and

uncertainty. Page seven of last month’s issue of this newsletter contained a

discussion of a term known as the prodome, a period in biomedical research

wherein an individual experiences some symptoms of an illness before meeting

formal diagnostic criteria. It ends once a patient meets such criteria and is

diagnosed with a disorder. Diagnostic standards are consequential. Not only can

they label and stigmatize, they have the power to confer or deny access to social

resources. Related features include fluidity and malleability, with the boundaries

between health and illness subject to redefinition and reorganization.

Neuroscientific research suggests the presence of prodromal phases for a growing

list of conditions, including schizophrenia and autism. Another example of possible

complexity and uncertainty is schizoaffective disorder (SAD), a controversial

diagnosis. Debate continues over its conceptualization, with some experts viewing

SAD as an independent disorder, while others see it as either a form of

schizophrenia or a mood disorder. If the focus is on an episode (DSM-IV,

Diagnostic and Statistical Manual of Mental Disorders) rather than on the

longitudinal course of the illness (DSM-V), the change likely could lead to reduced

rates of diagnosis of SAD, but controversy remains.

A paper appearing on February 16 of this year in the journal Theoretical Medicine

and Bioethics indicates that which concept of disease is assumed has implications

for what conditions count as diseases and, by extension, who may be regarded as

having a disease (disease judgements) and who may be accorded the social

privileges and personal responsibilities associated with being sick (sickness

judgements). The authors consider an ideal diagnostic test for coronavirus disease

2019 (COVID-19) infection regarding four groups of individuals: (1) positive and

asymptomatic, (2) positive and symptomatic, (3) negative, and (4) untested,

showing how different concepts of disease have an impact on the disease and

sickness judgements for these groups.

Which concept of disease is assumed has implications for what counts as a disease

(nosology). In 1981, the third edition of the DSM contained a definition of mental

disorder that included a harm requirement (necessitating distress or disability to the

individual) so that homosexuality could be coherently eliminated from the

catalogue of diseases. This move changed the applicability of what is called

disease judgement. Given that homosexuality does not cause harm and is therefore

not a disease according to the current definition of mental disorder, individuals who

are homosexual cannot be regarded as having a disease. Concepts of disease also

have implications for what are called sickness judgements about how the rights and

restrictions associated with forms of sickness are attributed to individuals by virtue

of their condition (e.g., entitlement to treatment and reimbursements, or the

obligation to surrender one’s driving license). Sickness is the social aspect of

disease. While disease and sickness judgements do not always correspond, the

concept of disease places constraints on what counts as sickness.