Health, Disease, and Illness

Concepts in Medicine

Arthur L. Caplan, James J. McCartney, Dominic A. Sisti, Arthur L. Caplan, James J. McCartney, Dominic A. Sisti

• Publisher: Georgetown University Press
• Year: 2004
• ISBN:
  9781589013384
• Topic: Médecine
• Subtopic: Déontologie en médecine

In the 1850s, "Drapetomania" was the medical term for a disease found among black slaves in the United States. The main symptom was a strange desire to run away from their masters. In earlier centuries gout was understood as a metabolic disease of the affluent, so much so that it became a badge of uppercrust honor—and a medical excuse to avoid hard work. Today, is there such a thing as mental illness, or is mental illness just a myth? Is Alzheimer's really a disease? What is menopause—a biological or a social construction?

Historically one can see that health, disease, and illness are concepts that have been ever fluid. Modern science, sociology, philosophy, even society—among other factors—constantly have these issues under microscopes, learning more, defining and redefining ever more exactly. Yet often that scrutiny, instead of leading toward hard answers, only leads to more questions. Health, Disease, and Illness brings together a sterling list of classic and contemporary thinkers to examine the history, state, and future of ever-changing "concepts" in medicine.

Divided into four parts—Historical Discussions; Characterizing Health, Disease, and Illness; Clinical Applications of Health and Disease; and Normalcy, Genetic Disease, and Enhancement: The Future of the Concepts of Health and Disease—the reader can see the evolutionary arc of medical concepts from the Greek physician Galen of Pergamum (ca. 150 ce) who proposed that "the best doctor is also a philosopher, " to contemporary discussions of the genome and morality. The editors have recognized a crucial need for a deeper integration of medicine and philosophy with each other, particularly in an age of dynamically changing medical science—and what it means, medically, philosophically, to be human.

PART I

Historical Discussions of Health, Disease, and Illness

PART I IS A SURVEY of various historical constructions of health and disease. It begins with an excerpt from On the Natural Faculties by Galen of Pergamum (ca. 150 ce). The Greek physician’s framework had a profound impact on medicine, and his synthesis of ancient medical theories, such as Hippocrates’ humors, and burgeoning anatomical knowledge was accepted as dogma for centuries. In this brief selection, Galen recounts descriptions of how the four humors—yellow and black bile, blood, and phlegm—are formed and explains their presence in relation to temperature. An imbalance of the humors results in disease.

In a similar way, an imbalance in what we might call “moral humors” may lead to diseases of the soul. For Maimonides (ca. 1150 ce), character traits that guide moderate and balanced deeds are the virtues of a healthy soul. The sick soul is directly analogous to the sick body: A person who is physically sick has a distorted palate and enjoys foods that are repugnant to healthy people. A person who is spiritually sick has a distorted vision of right conduct and acts immorally. Those who are physically ill and who do not seek treatment by a physician will die. And so, too, those who are spiritually ill and do not seek out healing of the Sages will die. The presentation by Maimonides highlights the conceptual interconnectedness of spiritual, moral, and physical health that is a latent feature of the nosological frameworks presented in other chapters of the book.

From classical humoral explanations to prototypes of the disease-as-entity framework, ROY PORTER AND G. S. ROUSSEAU present an historical survey of how gout was understood during the Renaissance. Among other Renaissance thinkers, the authors describe Swiss physician, alchemist, and philosopher Paracelsus’ (ca. 1500) important move in rejecting the notion that gout and renal calculi were caused by an endogenous imbalance of the humors. Rather, they write, Paracelsus was the first to claim that a disease—gout—was of exogenous origin and was often later personified (and deified) as taking up residence with its victim. This development notwithstanding, therapeutic remedies tended to assume that gout was of a more humoral origin, and it was treated as such.

As another example of the moral dimension of disease, gout was construed as a biological manifestation of Maimonides’ “diseases of the soul” brought on by excess and a lavish lifestyle. But although gout punished the extravagance of the rich, it also was the “disease of monarchs” and as such it was desirable to healthy plebeians. Indeed, Holy Roman Emperors, English lords, and even members of the Medici family were known to suffer from gout. The gouty sick role provided the well endowed with yet another excuse to avoid manual labor, assistance to others, or other social obligations. On the one hand, moralists such as Petrarch welcomed an attack of gout as an opportunity to lecture to victims on moral and spiritual growth by taming the excesses of the victim. On the other hand, a gouty affliction was a sign of social status and upward mobility and was celebrated.

In what is now understood to be a paradigmatic example of a pseudoscientific just-so story that reinforced a racist ideology, when taken in historical context SAMUEL CARTWRIGHT’S lecture is important on many levels. Cartwright’s discussion illustrates the social-ladenness of the concept of disease. Invoking the classic humoral theory of disease, Cartwright claims that for “negroes” to fully flourish, they ought to labor under the control of a white man. Cartwright argues that, for blacks, “red, vital blood” is essential for true human cogency and hard work infuses the black man’s blood with this vital force. Thus, hardworking slaves are better off than free blacks who are predisposed to malingering and “rascality” due to an excess of nonvital humors, “black blood,” and defective hemostasis. Cartwright also develops his naturalistic vision of the destiny of blacks as slaves on the basis of selective biblical and historical hermeneutics. In doing so, Cartwright medicalizes the unhealthy tendency of some slaves to seek freedom, or run away. Drapetomania is the disease that causes slaves to run away. Further developing the idea of that humoral excess or loss of hemostasis leading to malingering and rascality, the disease, Dysaesthesia Aethiopis, becomes part Cartwright’s nosology—a nosology that clearly illustrates how sociopolitical power structures are at once legitimized and reinforced by the concept of disease. Cartwright’s lecture presents an early example of the medicalization of deviance, a phenomenon explored in some detail in part III.

French historian, philosopher of science, and mentor of Michel Foucault, Georges Canguilhem reviews the various models of disease. The reader should approach this selection in the context of Canguilhem’s influence on medical epistemology, especially that of Michel Foucault in The Birth of the Clinic.

Two selections on the status of mental illness follow. THOMAS SZASZ argues that there is no such thing as mental illness, or, at least, that “mental illness” is a misnomer for a physiological disease of the brain. Further the phenomena typically referred to as “mental illness” may be the challenges of one’s life, a struggle that is altogether normal. “Mental illness” has reached mythic proportions in how it is applied and invoked by patients and mental health professionals. Again the moral dimension of illness is emphasized, as Szasz vigorously argues that “mental illness” is often the result of shortfalls in the struggle to live the moral life and is a tool of self-deceit for those who avoid an authentic life.

GEORGE ENGEL questions the medical model in toto, and, with particular regard to psychosocial diseases, he introduces another set of fundamental nosological problems. Should medicine deal only with somato-organic diseases and not psychosocial distresses, or is such a clear distinction impossible to draw? How and why did the mind-body dualism, which is the foundation of the medical model, develop and persist? Engel traces the thread of medical reductionism back to the Cartesian tradition and the Catholic Church’s dogmatic influence on metaphysical matters. By espousing a biopsychosocial model, Engel seeks to integrate the social, historical, and cultural and in so doing account for the lived experience of illness by some patients who show no apparent signs of disease. He seeks to move beyond the split of reductionists and exclusionists (Szasz being the latter) in hopes of fully recognizing the ills of those with anything from diabetes or schizophrenia to basic dysphoria. Engel presents the analogous case of the battle between molecular biologists (reductionists) and the psychosocialists as being resolved in part by the systems theorists who hold the holistic view that all levels of biological life are linked. He suggests applying this approach to medicine.

Finally, in a historical sketch of a practical problem, ROBERT A. ARONOWITZ discusses the criteria that are met when symptoms coalesce and are considered a disease. He recounts how various symptom clusters were construed as discrete diseases, which were discovered by physicians who sampled a very small number of patients. Indeed, the disciplinary matrix of institutional medicine of yesteryear created the potential for simpler disease recognition as (what might be seen today as) idiosyncratic signs and symptoms were accepted as diseases and reported out in medical journals and discussed among medical circles. Aronowitz presents asthma as an historical example of a symptom-based disease diagnosis. Despite individual variations in the symptoms of the disease, symptomatic asthma is a diagnosis that is well worth keeping for various institutional reasons. Aronowitz also asks us to consider how symptom clusters are transformed into legitimate diseases. He uses mental illness to craft his set of claims that legitimating factors are multidimensional.

CHAPTER 1
From On the Natural Faculties, II, VIII

GALEN [Translated by Arthur John Brock, M.D.]

NOW IN REFERENCE TO the genesis of the humours, I do not know that any one could add anything wiser than what has been said by Hippocrates, Aristotle, Praxagoras, Philotimus and many other among the Ancients. These men demonstrated that when the nutriment becomes altered in the veins by the innate heat, blood is produced when it is in moderation, and the other humours when it is not in proper proportion. And all the observed facts agree with this argument. Thus, those articles of food, which are by nature warmer, are more productive of bile, while those which are colder produce more phlegm. Similarly of the periods of life, those which are naturally warmer tend more to bile, and the colder more to phlegm. Of occupations also, localities and seasons, and, above all, of natures themselves, the colder are more phlegmatic, and the warmer more bilious. Also cold diseases result from phlegm, and warmer ones from yellow bile. There is not a single thing to by found which does not bear witness to the truth of this account. How could it be otherwise? For, seeing that every part functions in its own special way because of the manner in which the four qualities are compounded, it is absolutely necessary that the function [activity] should be either completely destroyed, or, at least hampered, by any damage to the qualities, and that thus the animal should fall ill, either as a whole, or in certain of its parts.

Also the diseases which are primary and most generic are four in number, and differ from each other in warmth, cold, dryness and moisture….

CHAPTER 2
Diseases of the Soul

MAIMONIDES [From The Essential Maimonides. Translations of the Rambam. Translated by Avraham Yaakov Finkel]

CHAPTER THREE

The Sick Soul

THE EARLY PHILOSOPHERS said that the soul, like the body, may be healthy or sick. The soul is healthy when its condition and that of its powers is such that it always does what is right and acts properly. The soul is sick when its condition and that of its powers is such that it always does what is wrong and acts improperly. The science of medicine studies the health of the body. People who are physically ill have distorted tastes and, therefore, think that bitter things taste sweet and sweet things bitter. They imagine that wholesome things are unwholesome, and they have a rapacious appetite and a lust for things such as dust and coal, as well as for very sharp and sour foods, which healthy people loathe and reject because they do not enjoy them and may even find them harmful. In the same way, people whose souls are sick—wicked and corrupt people—think that evil is good and that good is evil.¹ A wicked man constantly craves excess, which is harmful, but he believes it is beneficial because of the illness of his soul.

Healers of the Soul

When people who are unfamiliar with the science of medicine realize that they are sick, they consult a physician who tells them what they must do. He warns them not to eat certain things they mistakenly consider to be beneficial, and he prescribes things that they may find unpleasant and bitter. He does this so that their bodies may return to health and they will again choose the good and despise the bad.

Similarly, people whose souls become ill should consult the Sages, who are healers of the soul and will caution them not to indulge in evils that they mistakenly believe are good. In this manner, which I will discuss more fully in the following chapter, they may be cured by the art that heals man’s moral qualities. However, if a person who is morally sick does not realize that he is sick but imagines that he is well, or if he is aware that he is sick but does not try to get healed, then his end will be the same as the person who suffers from a physical ailment and who continues to indulge himself and does not seek a cure. He will surely die.

Those who know that they are sick, but nevertheless indulge in their pleasures, are accurately described in the Torah. The pleasure seeker says, “I will follow my heart’s desires. Let me add some moisture to the dry” (Devarim 29:18), meaning that he intends to satisfy his thirst [by satisfying his lusts], but thereby intensifies it.

A person who does not realize that he is sick is portrayed by King Solomon, “The way of a fool is right in his own eyes, but the wise man accepts advice” (Mishlei 12:15). Solomon is saying that the one who listens to the advice of the Sage is wise, for the Sage teaches the way that is truly right, not the path that the person wrongly sees as right. Solomon also says, “A road may seem right to a man, but in the end it is a road to death” (Mishlei 14:12). Again, regarding those who are morally ill and do not know what is harmful or beneficial, Solomon says, “The way of the wicked is all darkness; they do not know what will make them stumble” (Mishlei 4:19).

I will deal with the art of healing the soul in the next chapter.

CHAPTER FOUR

“Curing Diseases of the Soul”: The Middle Road

Good deeds are balanced deeds, occupying a middle ground between two equally bad extremes: too much, excess² and too little, insufficiency.³ Virtues are character traits, both inborn and acquired, that lie midway between the two extremes of excess and insufficiency.⁴ Good deeds are the direct result of these character traits.

To illustrate: Self-control lies midway between intemperate passion and a total absence of feeling for worldly enjoyment. Self-control is proper behavior, and the character trait that engenders self-control is an ethical one. But immoderate passion, which is at one extreme, and the total absence of feeling for worldly pleasure, at the other extreme, are equally deplorable. The character traits from which these two extremes result—intemperate passion from immoderation and absence of feeling from insensibility—are morally imperfect qualities. Similarly, generosity is the middle road between stinginess and wastefulness; courage, between recklessness and cowardice; dignity, between haughtiness and boorishness. Dignity is when one carries himself honorably and does not debase himself, haughtiness is when one seeks honor more than is deserved, boorishness is when one does things that are unbecoming. Friendliness is the middle road between aggressiveness and submissiveness.⁵ Humility is the middle course between conceit and self-abasement; contentedness, between greed and laziness; and goodheartedness, between meanness and extravagance. A good-hearted man is one who is intent on doing good to others, providing personal assistance, advice and money to the best of his ability, but without harming or disgracing himself. This is the middle road. The mean man, at one extreme does not want to help others, even if he himself will not suffer any loss, hardship, or damage through his generosity. The extravagant man, on the other hand, goes to extremes of generosity, even to the extent of personal damage, disgrace, hardship, and loss.

Tolerance is the middle course between anger and indifference. Sensitivity is the middle course between arrogance and timidness. According to our Sages, “A timid person cannot learn” (Avos 2:6); they did not say, “A sensitive person cannot learn.” They also said, “The sensitive one goes to the Garden of Eden” (Avos 5:24) and did not say, “The timid one goes to the Garden of Eden.” Therefore, I have made sensitivity the desirable mean and timidness the deplorable extreme. It is the same with the other qualities. We need to define them in terms that everyone agrees on, so that these ideas are clearly understood….

The Cure for the Diseases of the Soul

Good as well as faulty character traits can only be acquired or become embedded in the soul if one repeatedly prac...