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What are chronic diseases?

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Abstract

What kind of a thing are chronic diseases? Are they objects, bundles of signs and symptoms, properties, processes, or fictions? Rather than using concept analysis—the standard approach to disease in the philosophy of medicine—to answer this metaphysical question, I use a bottom-up, inductive approach. I argue that chronic diseases are bodily states or properties—often dispositional, but sometimes categorical. I also investigate the nature of related pathological entities: pathogenesis, etiology, and signs and symptoms. Finally, I defend my view against alternate accounts of the nature of disease.

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Notes

  1. Aristotle believed that there are only two basic categories: ‘substances’ (objects) and ‘accidents’ (properties) (Graham 1991). He made no room for fundamental processes or change in his Categories.

  2. Concept analysts might use induction to arrive at our concept of disease. Thus, the bottom-up inductive approach I will suggest is not necessarily opposed to concept analysis in method. But because my bottom-up approach does not aim towards a disease concept (it rather seeks to understand the metaphysics of disease tokens), it differs from concept analysis in its aim. In contrast, the bottom-up approach is opposed to the top-down approach not in aim but in method, as I will explain.

  3. See for overviews of the literature Ereshefsky (2009) and Boorse (2011).

  4. The ontological and physiological conceptions were important historically, though they are often understood differently by various contemporary authors (Hofmann 2001).

  5. Authors sometimes contrast dispositions with other kinds of realizable properties such as tendencies and propensities (Jansen 2007), but I will use ‘disposition’ as a broad term that encompasses all kinds of realizable properties.

  6. I left out a few other diagnoses included by Goodman and colleagues because the diagnoses were too nonspecific, accounting for multiple types of chronic disease; examples include ‘cardiac arrhythmias’ and ‘chronic kidney disease’. The diagnosis ‘cancer’, also listed by Goodman and colleagues, is especially nonspecific, and without further qualification could include many acute cancers.

  7. There is some confusion—perhaps even disagreement—concerning the definitions of asthma and heart failure. Asthma is often defined as a hyperresponsive state of the airways giving rise to variable airflow limitation (Bateman et al. 2008); but sometimes it is instead defined as a clinical syndrome, a constellation of specific symptoms (wheezing, dyspnea, coughing) resulting from this physiological state (Barnes 2012). Similarly, (left ventricular) heart failure is typically defined as a syndrome (dyspnea, fatigue, edema, rales) resulting from left ventricular dysfunction (Arnold et al. 2006; Mann and Chakinala 2012; McMurray et al. 2012; Moayedi and Kobulnik 2015); yet it is sometimes understood as left ventricular dysfunction itself. Nicholas Binney (2015) quotes Niels Gadsbøll et al. (1989) as distinguishing two distinct conceptual entities: heart failure as “clinical syndrome”, and heart failure as “disease state” (cardiac dysfunction). Whenever there is genuine conceptual ambiguity concerning a particular disease category, it is reasonable to follow Gadsbøll et al. in recognizing distinct concepts under the same name, which will often represent distinct things in the world.

  8. This conclusion is consistent with Boorse’s definition of a disease as an “internal state” (1977, p. 562).

  9. Peter Schwartz (2008) calls diseases like atherosclerosis and hypertension ‘risk-based diseases’ because their primary importance is that they increase the risk of other diseases or medical maladies.

  10. Hanna van Loo and Jan-Willem Romeijn (2015) analyze the metaphysics of psychiatric comorbidity.

  11. At first glance, hypertension might look like a counterexample to my generalization. Hypertension is considered a disease, and hypertension is synonymous with high blood pressure. Yet high blood pressure is a sign (or close to a sign—it is really a theoretical state inferred on the basis of measurements). Then isn’t this (pseudo)sign a part of the disease, as the disease per se? The distinction between a disease and its manifestations helps to disambiguate hypertension. It is not generally recognized that there are two senses of ‘hypertension’: as high blood pressure, and as a disease manifesting in high blood pressure. Yet we need this distinction if we are to make any sense of talk of ‘controlled hypertension’ (Chobanian et al. 2003; Wolf-Maier et al. 2004). Hypertension is controlled when a patient’s blood pressure is normalized, usually through drug therapy. If hypertension just is high blood pressure, then we should describe patients with controlled hypertension as having been cured of hypertension (at least, temporarily). But these patients often retain their chronic diagnosis, and that is because hypertension also refers to a disposition towards high blood pressure that endures even when its characteristic manifestation—high blood pressure—is removed. Applying the disease-manifestation distinction to this case helps untie a conceptual knot that we otherwise might trip over.

  12. Simon argues that the disease is ‘constructively real’ because his account adapts Ronald Giere’s constructive realism (1988, 1999).

  13. Similarly, Richard Scheuermann et al. (2009) propose that all diseases are dispositions. Although their proposal suggests a consistent ontology for diseases that could provide a revisionary, standardized disease terminology (their objective), it is not descriptively accurate (my objective).

  14. In rare cases, type II diabetes can go into ‘remission’ (Karter et al. 2014).

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Acknowledgements

Thanks to Nicholas Binney, Jeremy Simon, David Teira, Paul Thompson, Ross Upshur and anonymous reviewers for challenging and insightful feedback, and especially to Ayelet Kuper for suggesting several examples. Thanks also to the audience at the 2015 Philosophy of Medicine Roundtable for fruitful comments and discussion. I am thankful for funding support from the Canadian Institutes of Health Research. I have no conflicts of interest to declare.

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    Jonathan Fuller

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Fuller, J. What are chronic diseases?. Synthese 195, 3197–3220 (2018). https://doi.org/10.1007/s11229-017-1368-1

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