Skip to main content

Advertisement

Log in

Expanding disease and undermining the ethos of medicine

  • ESSAY
  • Published:
European Journal of Epidemiology Aims and scope Submit manuscript

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 identifies six ways that our conception of disease is expanded: by increased knowledge (epistemic), making more phenomena count as disease (ontological), doing more (pragmatic), defining 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 specific 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 effectively identifies or reduces human suffering. Otherwise we will deplete medicine and undermine the greatest asset in health care: trust.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

Notes

  1. With expansion I mean increasing the extension of disease.

References

  1. De Sauvages F. Nosologia methodica sistens morborum classes. Amsterdam: Fratrum de Tournes; 1768/1968.

  2. World Health Organization. International statistical classification of diseases and related health problems. Geneva: World Health Organization; 2004.

    Google Scholar 

  3. Kawa S, Giordano J. A brief historicity of the diagnostic and statistical manual of mental disorders: issues and implications for the future of psychiatric canon and practice. Philos, Ethics, Humanit Med: PEHM. 2012;7:2. https://doi.org/10.1186/1747-5341-7-2.

    Article  PubMed  Google Scholar 

  4. World Organization of Family Doctors (WONCA) International Classification Committee, ICPC-2. International classification of primary care. Oxford: Oxford University Press; 1998.

    Google Scholar 

  5. World Health Organization. International classification of functioning, disability and health: ICF. Geneva: World Health Organization; 2001.

    Google Scholar 

  6. Kaplan RM, Ong M. Rationale and public health implications of changing CHD risk factor definitions. Annu Rev Public Health. 2007;28:321–44.

    Article  PubMed  Google Scholar 

  7. Doust J, Vandvik PO, Qaseem A, et al. Guidance for modifying the definition of diseases: a checklist. JAMA Intern Med. 2017;177:1020–5. https://doi.org/10.1001/jamainternmed.2017.1302.

    Article  PubMed  Google Scholar 

  8. Glymour MM, Brickman AM, Kivimaki M, et al. Will biomarker-based diagnosis of Alzheimer’s disease maximize scientific progress? Evaluating proposed diagnostic criteria. Eur J Epidemiol. 2018;33(7):607–12. https://doi.org/10.1007/s10654-018-0418-4.

    Article  CAS  PubMed  Google Scholar 

  9. Hofmann B, Welch HG. New diagnostic tests: more harm than good. BMJ (Clin Res Ed. 2017. https://doi.org/10.1136/bmj.j3314.

    Article  Google Scholar 

  10. Reid L. Is an indistinct picture “exactly what we need”? Objectivity, accuracy, and harm in imaging for cancer. J Eval Clin Pract. 2018;24(5):1055–64.

    Article  PubMed  Google Scholar 

  11. Hutchinson BD, Navin P, Marom EM, Truong MT, Bruzzi JF. Overdiagnosis of pulmonary embolism by pulmonary CT angiography. AJR Am J Roentgenol. 2015;205(2):271–7. https://doi.org/10.2214/ajr.14.13938.

    Article  PubMed  Google Scholar 

  12. Prasad V, Rho J, Cifu A. The diagnosis and treatment of pulmonary embolism: a metaphor for medicine in the evidence-based medicine era. Arch Intern Med. 2012;172(12):955–8. https://doi.org/10.1001/archinternmed.2012.195.

    Article  PubMed  Google Scholar 

  13. Wiener RS, Schwartz LM, Woloshin S. When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ. 2013;347:f3368. https://doi.org/10.1136/bmj.f3368.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Rogers WA, Mintzker Y. Getting clearer on overdiagnosis. J Eval Clin Pract. 2016;22(4):580–7. https://doi.org/10.1111/jep.12556.

    Article  PubMed  Google Scholar 

  15. Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care: how might more be worse? JAMA, J Am Med Assoc. 1999;281(5):446–53.

    Article  CAS  Google Scholar 

  16. Welch HG. Less medicine, more health: 7 assumptions that drive too much medical care. Boston: Beacon Press; 2015.

    Google Scholar 

  17. Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010;102(9):605–13. https://doi.org/10.1093/jnci/djq099.

    Article  PubMed  Google Scholar 

  18. Narod SA. Approaches of the treatment of DCIS. Breast. 2018;37:161–2.

    Article  PubMed  Google Scholar 

  19. Esserman LJ, Thompson IM, Reid B, et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol. 2014;15(6):e234–42. https://doi.org/10.1016/S1470-2045(13)70598-9.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Nickel B, Moynihan R, Barratt A, Brito JP, McCaffery K. Renaming low risk conditions labelled as cancer. BMJ. 2018;362:k3322.

    Article  PubMed  Google Scholar 

  21. Bynum B. Drapetomania. Lancet. 2000;356(9241):1615.

    Article  CAS  PubMed  Google Scholar 

  22. Kmietowicz Z. Recognise obesity as a disease to reduce prevalence, says RCP. BMJ. 2019;364:l45.

    Article  PubMed  Google Scholar 

  23. Marchant GE, Campos-Outcalt DE, Lindor RA. Physician liability: the next big thing for personalized medicine? Pers Med. 2011;8(4):457–67. https://doi.org/10.2217/pme.11.33.

    Article  Google Scholar 

  24. De Ville K. Medical malpractice in twentieth century United States. The interaction of technology, law and culture. Int J Technol Assess Health Care. 1998;14(2):197–211.

    Article  PubMed  Google Scholar 

  25. Hofmann B. Limits to human enhancement: nature, disease, therapy or betterment. BMC Med Ethics. 2017;18(56):1–11. https://doi.org/10.1186/s12910-017-0215-8.

    Article  Google Scholar 

  26. Hofmann B. Looking for trouble? Diagnostics expanding disease and producing patients. J Eval Clin Pract. 2018. https://doi.org/10.1111/jep.12941.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Quebec Medical Association. Overdiagnosis: findings and action plan. Quebec: Quebec Medical Association; 2014.

    Google Scholar 

  28. Clark CC. Trust in medicine. J Med Philos. 2002;27(1):11–29.

    Article  PubMed  Google Scholar 

  29. O’neill O. Autonomy and trust in bioethics. Cambridge: Cambridge University Press; 2002.

    Book  Google Scholar 

  30. Persson I, Savulescu J. Moral transhumanism. J Med Philos. 2010;35(6):656–69.

    Article  PubMed  Google Scholar 

  31. Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ. 2002;324(7342):886–91.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Moynihan R. The making of a disease: female sexual dysfunction. BMJ. 2003;326(7379):45–7.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Moynihan R. Scientists find new disease: motivational deficiency disorder. BMJ: Br Med J. 2006;332(7544):745.

    Article  Google Scholar 

  34. Moynihan R. Medicalization. A new deal on disease definition. BMJ. 2011;342:d2548. https://doi.org/10.1136/bmj.d2548.

    Article  PubMed  Google Scholar 

  35. Bickerdike L, Booth A, Wilson PM, Farley K, Wright K. Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open. 2017;7(4):e013384.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Paprica PA, Culyer AJ, Elshaug AG, Peffer J, Sandoval GA. From talk to action: policy stakeholders, appropriateness, and selective disinvestment. Int J Technol Assess Health Care. 2015;31(4):236–40.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Hughes E, McKenny K. Decommissioning and disinvestment toolkit 2013–2014 Rayleigh. Essex: Castle Point and Rochford Clinical Commissioning Group; 2013.

    Google Scholar 

  38. Haas M, Hall J, Viney R, Gallego G. Breaking up is hard to do: why disinvestment in medical technology is harder than investment. Aust Health Rev. 2012. https://doi.org/10.1071/ah11032.

    Article  PubMed  Google Scholar 

  39. Soril LJJ, Seixas BV, Mitton C, Bryan S, Clement FM. Moving low value care lists into action: prioritizing candidate health technologies for reassessment using administrative data. BMC Health Serv Res. 2018;18(1):640. https://doi.org/10.1186/s12913-018-3459-1.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Scotland G, Bryan S. Why do health economists promote technology adoption rather than the search for efficiency? A proposal for a change in our approach to economic evaluation in health care. Med Decis Mak: Int J Soc Med Decis Mak. 2017;37(2):139–47. https://doi.org/10.1177/0272989x16653397.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Bjørn Hofmann.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hofmann, B. Expanding disease and undermining the ethos of medicine. Eur J Epidemiol 34, 613–619 (2019). https://doi.org/10.1007/s10654-019-00496-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10654-019-00496-4

Keywords

Navigation