The Social Construction of “Disease”
The Social Construction of “Disease”
A disease state is not identical with the biological state but it is metaphysically dependent on it
I squealed in excited agreement when I first read the following sentence in Shane Glackin’s wonderful paper, “Grounded disease: Constructing the social from the biological in medicine” (The Philosophical Quarterly, 2019):
“I think a thoroughgoing normativist can and should simply refuse the demand for some extra facts which determine whether the appropriate response is medical or non-medical; the question can be settled by again appealing to our values.”
There are many who strongly feel that an adequate concept of disease or disorder should tell us what is specifically medical about these conditions or why these conditions warrant medical treatment in the first place. Glackin explains this objection: “It won’t do just to say that diseases are the disvalued conditions for which medical treatment is warranted; again, the fact that something is a disease is supposed to tell us why medical treatment is the appropriate intervention, and not just to record a determination we have already arrived at.”
This sort of objection is a pet peeve of mine. Medicine is a human and social institution; it emerged to address experiences of “illness” and promote “health,” among other things. The boundaries of medicine coexist with other human domains such as law, psychology, social work, nutrition, education, etc. in complicated ways that reflect the contingencies of human history. It is odd to think that this messy human practice has to depend on some intrinsic fact of nature that defines what disease is. It gets the order of things wrong! And in the case of psychiatry, it sets up a contentious Szaszian battle where the appropriateness of a medical response to psychological suffering depends on speculative ideas about cellular pathology, evolutionary design, or some such thing.
Glackin is correct when he says:
“Even if the disease-concept were entirely value-free, we could not—for familiar Humean reasons—expect to infer from it without challenge normative conclusions about the treatment of patients.”
With regards to the objection that normative accounts of health and disorder, given their perceived relativism, make them “(un)appealing to those who wish to use the concept of health to help ground a normative social justice account” (Kukla), Glackin offers the perfect response:
“… it is no objection to Social Constructivism, or to any other normativist account of disease, that it does not provide us with an expedited route to socially just treatment of patients; no version of the concept is going to do that. If we want social justice, in other words, we must do the hard, patient work of argument and advocacy for it; just agreeing on the descriptive facts will not be enough.”
It gives me so much pleasure to see this asserted with such clarity!
Let’s step back, however. I’ll say more about Glackin’s overall argument in this paper to give the readers more context.
Normativism is the view that the concept of disease (or disorder) is inherently evaluative, based on value judgments, and naturalism is the view that it is purely empirical. Normativists argue that the classification of a condition as a disorder depends in an essential way on some sort of evaluative judgement. Naturalists argue that this classification depends primarily on natural facts, such as facts about statistical deviation from species typical functioning or failure of mechanisms to perform functions for which they are naturally selected. There are also hybrid positions that argue that “dysfunction” depends on natural facts while “disorder” depends on the combination of dysfunction and evaluative judgments (“harmful dysfunction”). I will also consider these hybrid positions as naturalistic here. Social constructivism, the way Glackin understands it, is a variety of normativism in which the relevant evaluative judgment is a particular sort of social attitude.
The normativist and social constructivist positions encounter immediate incredulity from most people. People point out, quite sensibly, that disease processes such as bowel cancer are unaffected by our perceptions or attitudes towards them. Our evaluative judgments neither alter the biological changes nor the negative consequences of their progression. So, in what sense are disorders evaluative? Philosophical advocates can find it hard to effectively communicate their view in such a way that it overcomes this incredulity. Glackin takes on the task in this paper to remedy that in a philosophically rigorous way.
To understand this, we need to distinguish between several key questions. The status question asks what conditions must be met for an individual to be considered to have a specific disorder (say, adenocarcinoma of the colon). The constitution question asks about the physical basis of an individual’s condition. The constitution question seeks biological mechanisms that exist independent of any attitudes we may have towards them, such as the biological changes that constitute adenocarcinoma. Then there is the general status question: What characteristics provide a basis for categorizing a condition as a disorder?
Glackin writes:
“There must be some—possibly disjunctive—feature held in common by e.g. leukaemia, scaphoid fracture, and schizophrenia, but not by e.g. homosexuality, below-average height, or pierced ears. And social constructivists believe that what will count as plausible answers to the constitution question can’t get us anywhere towards answering the general status question; lesions, or deviations from the statistical norm of functioning in a reference class, or harmful etiological dysfunctions (e.g. Szasz 1960; Boorse 1975, 1977; Wakefield 1992), are not even the right sort of thing to look to for an answer. The most plausible answer, we claim, is a particular sort of social attitude.”
Social constructivists face the task of explaining the relationship between biological states that exist independently of our attitudes or beliefs and disorder status that is based on our social attitudes.
Glackin: “As normativists, and constructivists, we should not deny the obvious point that disease-states are objective natural phenomena. It is an objective, natural fact about a person—again, if anything is—that they have leukaemia, or a scaphoid fracture, or (assuming arguendo, but more controversially, the diagnostic validity of psychiatric disorders) schizophrenia. But normativists hold that it is a contingent fact about any such state that it is a disease, and does not reflect any intrinsic feature that it possesses; an individual in any of these objective natural states might or might not be properly regarded as diseased, depending upon other background factors. Naturalists may plausibly agree thus far; the defining feature of normativism is that it believes at least some of these additional factors to be evaluative… A disease, then, will not be identical with the underlying biological or behavioural state, but it will be metaphysically dependent upon it.”
Glackin uses the metaphysical notion of grounding to explain this relationship:
“the state of being ill or having a disease is grounded by the patient’s underlying biological or behavioural state. And this grounding relation, according to the social constructivist, in turn exists because the background evaluative facts are as they are.”
“Thus, on the view I propose, the clinical judgement that ‘x is infected with rubulavirus and x has inflamed parotid glands, and …’ grounds the judgement that ‘x has a disease’ just in case the clinical state of being infected with rubulavirus and having inflamed parotid glands, etc., is socially evaluated in a particular way.”
Glackin develops a toy version of social constructivism in the paper that is not intended to defend against all objections and counter-examinations but to show that even this toy version is resistant to some popular criticisms of social constructivism. The general template is as follows: A biological or behavioral state is judged to be a disease just in case it is regarded as: (a) possessing evaluative features (to be specified) and (b) therefore enjoining attitudes or actions (to be specified) on the part of others.
(For example: “any biological or behavioural state which is generally regarded in our society as undesirable and therefore as demanding sympathy and medical intervention”)
Who gets to judge and evaluate? Glackin says that both individuals and societies can make judgements about disease, and sometimes these judgements may come into conflict. There are multiple stakeholders (e.g., people with the condition, their families, clinicians, researchers, funders, etc.), and they have to engage in a process of dialogue:
“What a ‘liberal’ approach involves is the recognition that, since the criteria for a judgement of disease are evaluative, these groups—or the individuals that compose them—may on (usually rare) occasion be unable to come to a consensus about some particular condition; and as liberal political theory holds, the best response to an irreconcilable clash of values is not to impose one faction’s views on all parties, but to negotiate as wide as possible a modus vivendi, which will allow all parties to proceed on a basis of respectful disagreement, and tolerable compromise.”
It is important to be clear about what sorts of disagreements we are talking about. Clinicians are usually interested in disagreements about “grounding facts,” whether the relevant biological or behavioral changes are present to begin with, and they are not typically interested in the general criteria on the basis of which the biological or behavioral changes are characterized as “disorders.”
“So when an oncologist asks whether her patient is sick, what she is interested in is whether or not his cells are cancerous, and how they are behaving. She is not concerned, qua oncologist, with the question of what the anchoring and grounding conditions are or should be, but only with whether her patient’s condition meets them or is at risk of doing so.”
Philosophers are usually interested in the criteria for counting something as a disease—the general status question. When people disagree about criteria or when people change our minds about the relevant criteria, the grounding facts do not change. The biological or behavioral state is not thereby “cured,” nor does it cease to exist. The state remains as it is, but our attitude towards it and the sort of care provided, if any, change. It is no longer classified as a disorder.
Doesn’t this lead to problematic relativism where people who, for example, call “homosexuality” a disease cannot be said to be wrong, and that in such situations, we can only say that our values are different? Glackin doesn’t think so, and I agree. Glackin points out that committing to social constructivism does not commit us to relativism:
“Social Constructivism, along with the grounding analysis I’ve given here, aims to capture the nature of judgements about disease, but it in no way commits us to accepting them. After all, we are not committed to accepting the evaluative judgements which comprise them either, unless we have adopted a rather problematic metaethics. But most of us don’t believe that the sort of moral values I’ve appealed to in defining the concept are relative. Some societies might treat homosexuality, or bourgeouis deviationism, or left-handedness as diseases; but they are wrong to do so in just the same way that some societies are wrong to allow slavery, or liquidate the kulaks, or leave their poor to starve… Unless we are moral relativists, however, we have no reason to suppose that [all] sets of evaluations are right. And if we are convinced moral relativists, it is hard to see why we might find medical relativism particularly objectionable.”
Well said!
My own view is a bit more complicated than the view that the relevant evaluative judgment is a particular sort of social attitude. For one, I take the view, following Peter Zachar, that the domain of disorders (including mental disorders) is an “imperfect community,” and lacks an essence. I do think that there is no value-free answer to the question of what makes something a disorder, nor do I think that value-free definitions of “dysfunction” produce clinically satisfactory concepts of disorder. Disorder judgments—the way they are employed in medicine and psychiatry—cannot simply be understood in terms of statistics, neurobiology, or evolutionary history. These judgments are enmeshed with sociocultural and sociopolitical considerations. Disorder status is not a fact of nature that can be scientifically discovered, but it is grounded in facts of nature. I agree with Glackin that this doesn’t commit us to relativism. As I wrote in the post The Politics of Psychiatric Classification:
“It also doesn’t mean that disorder attribution is arbitrary or purely relative, nor does it mean that there aren’t good or bad answers. If we call something a disorder because of social prejudice, we have made an error. The nature of this error is normative. We have misunderstood and misapplied the norms for disorder judgments. These norms include judgments of typicality, rationality, adaptiveness, distress, disability, harm to others, and impediments to well-being in various conjunctions and combinations. Over time, we’ve learned that it's not enough to say that something is out of the ordinary, abnormal, irrational, or strange; it also has to be linked to the right kinds of harm. Disorder judgments are intended to identify states that threaten an individual’s adaptive functioning. Since this functioning is always in a particular social context, the judgments inevitably have a social and political dimension. When conditions involve a risk to others (e.g., pedophilia, pyromania, etc.), the needs of the individual have to be balanced against the needs of society. Disorder judgments, therefore, require a formal or informal process of negotiation among stakeholders. People with the condition are the most important stakeholders, but there are others as well, such as their families, clinicians, funders who will pay for healthcare and research, the legal system, etc. Just to make it clear: the process is, under ideal circumstances, constrained by the relevant considerations. It is not whimsical; it is not anything-goes relativism, where anything can be a disorder just because we want it to be.”
See also:
Well said!
This also relates to a paper of mine from last year, "a wide-enough range of test environments for psychiatric disabilities". I discuss an earlier paper by Rachel Cooper where she introduces the idea of "test environment", which I think often plays an implicit role in arguments even when people don't explicitly talk about it. The idea is that we can tell, at least in principle, if someone is neurodivergent or inherently ill/impaired by placing them (for real or as a thought experiment) in different test environments. If there's an environment in which they do fine, they're just neurodivergent, even if they struggle in their actual situation. If they'll struggle in any realistic test environment, they're ill/impaired.
Cooper says herself that it's an ethical and political question how wide a range of test environments we should consider here. She thinks it's clear that someone who only does fine in an unrealistic and bizarre society which is completely tailored to this individual and their needs still counts as impaired. But this still leaves room for lots of disagreement and debate over the relevant range.
I argue that there's a regrettable tendency to focus solely on adjustments that can be done locally, in school, the workplace, at home, and forget that some people might do much better if various large-scale political changes happened.
In any case, you absolutely cannot draw the line between inherently neutral neurodivergences and inherently harmful impairments without value judgments, like how wide a range of test environments we OUGHT TO consider. You can't draw the line by mere empirical investigations, that's impossible.
This is an important paper, and you have provided a very good discussion, Awais. Much more could be said, but I would like to focus on your well-founded statement that,
"Medicine is a human and social institution; it emerged to address experiences of “illness” and promote “health,” among other things. The boundaries of medicine coexist with other human domains such as law, psychology, social work, nutrition, education, etc. in complicated ways that reflect the contingencies of human history. It is odd to think that this messy human practice has to depend on some intrinsic fact of nature that defines what disease is. It gets the order of things wrong! And in the case of psychiatry, it sets up a contentious Szaszian battle where the appropriateness of a medical response to psychological suffering depends on speculative ideas about cellular pathology, evolutionary design, or some such thing."
Indeed, it is precisely the "Szaszian battle" that has muddied the debate over disease for the past 60 or more years, as I have argued since 1979! [1] And since you raise the issue of "cellular pathology", it is important to note that Szasz misread and misunderstood his hero, Rudolf Virchow, who (remarkably!) stated the following:
"‘What we call disease is solely an abstract concept with the help of which we separate particular phenomena of daily life from all others, without there being such a separation in nature itself.’ [2]
Philosophers will continue to debate the concepts of disease, disorder, illness, malady, morbus, etc. until the stars fall from the sky. Physicians know that these matters are "settled" (pragmatically) not in learned journals, but in the clinic, hospital and waiting room. More on all this in an upcoming article for Psychiatric Times, titled, "Misreading Virchow."
Regards,
Ron
Ronald W. Pies, MD
1. Pies R. On myths and countermyths: more on Szaszian fallacies. Arch Gen Psychiatry. 1979 Feb;36(2):139-44. doi: 10.1001/archpsyc.1979.01780020029002. PMID: 369469.
2. Virchow R. Handbuch der speciellen pathologie und therapie. Bd. 1: allgemeine
stoerungen. Erlangen: Enke, 1854. [for translation from the original German, see:
Gerber A, Hentzelt F, Lauterbach KW. Can evidence-based medicine implicitly rely on current concepts of disease or does it have to develop its own definition? J Med Ethics. 2007 Jul;33(7):394-9. doi: 10.1136/jme.2006.017913. PMID: 17601866; PMCID: PMC2598145. This is an excellent paper, with a very useful diagram [Figure 3], showing that "...there is a grey zone—that is, a zone where healthy and sick may not clearly be separated..."