Two distinguishing characteristics of the health care sphere are complexity and uncertainty. Last month’s issue of this newsletter contained a discussion of a term known as the prodrome, 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), this difference likely could lead to changed rates of diagnosis of SAD, but controversy remains over classification.

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 (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.

The third edition of the DSM in 1981 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. Thus, attainment of greater clarity among these concepts has the potential to improve clinical care.

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HEALTH CARE COMPLEXITY AND UNCERTAINTY

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