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Expanding Disease and Undermining the Ethos of Medicine European Journal of Epidemiology (2019) 34:613–619 https://doi.org/10.1007/s10654-019-00496-4 ESSAY Expanding disease and undermining the ethos of medicine Bjørn Hofmann1,2 Received: 12 November 2018 / Accepted: 12 February 2019 / Published online: 22 February 2019 © Springer Nature B.V. 2019 Abstract The expansion of the concept of disease poses problems for epidemiology. Certainly, new diseases are discovered and more people are treated earlier and better. However, the historically unprecedented expansion is criticised for going too far. Overdiagnosis, overtreatment, and medicalization are some of the challenges heatedly debated in medicine, media, and in health policy making. How are we to analyse and handle the vast expansion of disease? Where can we draw the line between warranted and unwarranted expansion? To address this issue, which has wide implications for epidemiology, we need to understand how disease is expanded. This article identifes six ways that our conception of disease is expanded: by increased knowledge (epistemic), making more phenomena count as disease (ontological), doing more (pragmatic), defning more (conceptual), and by encompassing the bad (ethic) and the ugly (aesthetic). Expanding the subject matter of medicine extends its realm and power, but also its responsibility. It makes medicine accountable for ever more of human potential dis-eases. At the same time it blurs the borders and undermines the demarcation of medicine. Six specifc advices can guide our action clarifying the subject matter of medicine in general and epidemiology in particular. To avoid unlimited responsibility and to keep medicine on par with its end, we need to direct the expansion of disease to what efectively identifes or reduces human sufering. Otherwise we will deplete medicine and undermine the greatest asset in health care: trust. Keywords Concept of disease · Expansion · Diagnostics · Overdiagnosis · Philosophy · Responsibility · Ethics · Epistemology · Ontology · Aesthetics Introduction Part of this expansion1 is due to a historically unprec- edented extended knowledge of diseases, their mechanisms, With the great advances in science and technology disease and their causes. We know more about what causes pain and is expanded in a number of ways. From the 2400 diseases sufering than ever before. At the same time we have gained classifed in Sauvage’s Nosologia methodica of 1768 [1] to insights in risk factors, processes, precursors, and indicators the 45,000 disease codes the WHO’s International Classif- of disease. Although only some of these may cause pain and cation of Disease of ICD-10 [2] there is a huge extension of sufering, we identify and handle them as disease. medicine. There was a corresponding increase in the number No doubt, the expansion has many positive consequences, of disorder categories in DSM from 182 in 1968 to 297 in for example in diferentiating existing diseases in more pre- 1989 [3], in ICPC’s categories [4], as in ICF [5]. Hence cise and actionable disease entities—or such as diagnosing, there has been a substantial expansion of disease categories treating, and helping more people—earlier. However, the and entities with the efect that more people than ever are expansion also has some negative implications such as over- diagnosed with a disease [6]. diagnosis, overtreatment, medicalization, as well as adverse efect of futile diagnostics and treatment and increased anxi- ety and altered self-conception from becoming diagnosed. Some attention has been given to the side-efects of expand- * Bjørn Hofmann ing disease defnitions, and guidelines to ensure appropri- [email protected] ate expansions have been suggested [7, 8]. How these can 1 Department for the Health Sciences, Norwegian University address the unprecedented number of new biomarkers, risk of Science and Technology (NTNU), Gjovik, Norway factors, and indicators that emerge from the convergence of 2 Centre of Medical Ethics, University of Oslo, PO Box 1130, Blindern, N-0318 Oslo, Norway 1 With expansion I mean increasing the extension of disease. Vol.:(0123456789)1 3 614 B. Hofmann omics, Big Data, Artifcial Intelligence and enormous invest- disease may make us look harder and fnd more cases, ments [9] is still to be decided. and extend the number of persons being diagnosed with a disease. Second, the same can happen when introduc- ing more precise tests [10]. New methods for detecting Expanding disease pulmonary embolism (high-resolution CT scan) greatly enlarged the extension of pulmonary embolism [11–13]. The expansions of disease come in six fundamentally dif- Third, increased attention or precision may make us low- ferent types: by expanding or knowledge of disease mecha- ering diagnostic detection thresholds [14–16], further nisms (epistemic); by extending the phenomena that defne increasing the number of persons being considered to have disease (ontologically); by what we can do (pragmatic); the disease. This connects to the fourth way that knowl- by what we defne as disease (conceptual); by what we edge expands disease: increased precision makes us fnd defne as bad (ethic); and by what we consider to be ugly milder cases. When more milder cases are detected and (aesthetic). Figure 1 illustrates the dimensions of disease treated, success rates increase [17], spurring more empha- expansion. sis on testing and further expanding disease. The epistemic Table 1 gives an overview of various ways that disease extension relates to an ontological expansion of disease. is expanded with its implications. More things are made disease (ontological) Expanding disease by expanding knowledge Disease is expanded by making more things count as dis- (epistemic) ease. This can happen in several ways. First, new phenomena can come to defne diseases directly. This can be phenomena Disease is expanded through the great increase in medi- such as behaviour (ADHD), emotions (sorrow, dysphorias), cal knowledge. On the positive side, increased knowledge sensations (dry eye), or hormones (Low-T). While fnding increases the numbers of diseases by establishing new new things that can explain and defne disease is crucial in disease entities or by dividing existing diseases in other medicine, e.g., in the discovery of microbes, making new and more precise disease enteties. However, extended things disease is also at the core of the type of expansion knowledge also has some potentially less favourable that is called medicalization. Second, new phenomena can efects on the extension of disease. First, more knowledge defne disease indirectly, through various indicators, such of mechanisms, processes, precursors, and risk factors of as biomarkers (beta-amyloid), risk factors (blood pressure), and precursors (polyps, HPV). These phenomena may come to be included in the defnition of the disease, as in the case with beta-amyloid and Alzheimer’s disease. This expansion can be both helpful and harmful. Doing more: defning more (pragmatic) “Can do–will do” seems to be another strong drive in expanding disease. When a condition can be manipulated or treated, it rapidly is made a disease. Bariatric surgery has contributed making obesity a disease. Being able to meas- ure and manipulate blood pressure and cholesterol levels has made these conditions classifed as diseases (hyperten- sion and hypercholesterolemia). As already mentioned, the efects of lowering treatment thresholds reinforce this efect. No doubt, the ability to do more can certainly be good, but not always, e.g., in cases where conditions unnecessarily are identifed as diseases or where it implies more harms than benefts. Fig. 1 Six ways of disease expansion 1 3 Expanding diseaseand underminingthe ethosof medicine Table 1 Various ways of expanding disease with potential positive and negative implications and examples Type of expansion Way of expansion Example Potential positive implication(s) Potential negative implication(s) Knowing more about what can be Increased knowledge of mechanisms, Polyps, infectious agents Avoiding disease (primary preven- Adverse side efects from treat- made disease (epistemic) processes, precursors and risk tion) ment, overtreatment factors Gaining knowledge of causes, treat- ment More precise tests Beta-amyloid, CT-detected pul- More accurate diagnosis Overdiagnosis monary emboli, High-sensitivity cardiac troponin  ,Lowering diagnostic thresholds Diabetes Reducing underdiagnosis Overdiagnosis, indication creep (cut-ofs) Blood pressure subsequent overtreatment Cholesterol level Making more things disease (onto- New (experienced or observed) phe- Male baldness, menopause, sexual Increased help Medicalization logical) nomena defne disease function, sorrow, low-T, dry eye, drapetomania, ADHD Indirectly defning disease by indica- Biomarkers, such as troponin, Avoiding consequences of disease Overdiagnosis, overtreatment tors, such as biomarkers, precur- glucose control, atypical ductal (secondary prevention) sors, and risk factors hyperplasia, osteopenia, micro- calcifcations Pragmatic Increased actionability: can do, will Obesity, hypertension, hyper-choles- Preventing disease and sufering Side efects, harm do terolemia Conceptual Expanding theories and models of Ductal carcinoma in situ (DCIS), Preventing disease and sufering Overdiagnosis, overtreatment disease (including indolent and cervical intraepithelial neoplasia (secondary prevention) regressive cases) Ethical expansion Being directed by our moral impera- Deviant behavior Increased help to persons and groups Medicalization
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