Karl Popper suggests that we need social theory to be able to predict the unintended consequences of our actions. Theorising is not an activity widespread among suburban practitioners. It seems impertinent, and likely to expose one to public criticism and private ridicule. As Jessica Mitford said of raising children, I say of medicine: It is an activity which takes up all the brain, and none of the mind.
When doctors determine who is, or is not, legitimately ill for the purpose at hand, they are hiding behind a taken-for-granted authority and expertise in this area. But as soon as they have to explain their decisions to ordinary men and women and, using ordinary language, to justify why they regard one person complaining of symptoms as ill and the other not, they soon come to the boundaries of medical knowledge. There is a inclination to assume both good will and competence to doctors. A refusal to share this world view is rather too frightening. Gorovitz and McIntyre in their paper "Towards a Theory of Medical Fallibility" warn:
"No species of fallibility is more important than fallibility in medical practice. The physician's propensity for damaging error is widely denied, perhaps because it is so widely feared."
We ourselves are in some confusion. Merskey points out that it is commonly believed that one could get away with anything with the help of a doctor's note, and he cites the literary example of William Wycherley's Restoration Comedy, "The Country Wife". The plot turns on the deception practised by a man who persuades his doctor to put it about that he has become impotent so that his acquaintances trust him with rather ready access to their wives and daughters. Other possibilities include release from military service, disability payments and nursing and domestic help services, as well as legal excuses and entitlement to altered family relationships. The key to this is that the doctor must state that the patient has a disease. Merskey, a psychiatrist suggested
"that what doctors treat can be accepted as disease provided that we recognise that the significance of disease must vary with circumstances."
Kendell argues that "equating illness with complaint allows the individual to be the sole arbiter of whether he is ill" and any definition of disease that boils down to "what patients complain of" and "what doctors treat" is worse than no definition at all, as:
"disease is free to expand and contract with changes in social attitudes and therapeutic optimism and is at the mercy of idiosyncratic decisions by doctors and patients".
Merskey's view however should not be dismissed lightly. The definition fails and must fail because it is entirely circular, yet it cannot be ignored as it is precisely this view of illness and disease that informs today's debate, passes for "common knowledge" and forms the rationale for the interventions of doctors into all spheres of life. It is the view that the public and the courts tend to adopt in compensation matters.
Kraupl-Taylor tries harder and defines
"an elementary morbus which is one which originates in a particular kind of past pathological event. Its diagnosis depends on the discoverable presence of pathological abnormalities which are concomitant with clinical manifestations, if any, from which the original past pathological event can be inferred. Elementary morbi are the disease entities of today."
So he says. My experience suggests that some morbidity did not originate in any pathological event, but in a normal physiological event which was medicalised.
In an ideal world to have a morbus would be consistent with being in the "sick role", as defined by Talcott Parsons, eager to recover, and receiving rational and effective therapies from affectively neutral physicians. The ideal is defined in terms of the assumed good intentions of both parties. However neither doctors nor patients conform to Parsons' idealised affective neutrality, nor are they steeped in ideology, nor innocent of fiscal motivation. Some get mindlessly involved in the pas de deux of giving and receiving interventions, code named treatments.
Baroness Wootton suggests that a distinction be made between "what doctors treat" and "what is treatable by medical means", that is between what doctors do when they are behaving in the special fashion peculiar to their profession, and what they do when they drop the Aesculapian mantle and behave as ordinary men and women."
In trying to theorise a model of understanding the elements that contribute to morbidity, I soon found that the language of medicine was inadequate for the purpose. The medical model or bio-psycho-social model is commonly offered and used for medical, educational, social and political purposes.
It is two dimensional and can be drawn on a sheet of paper, but this perhaps limits our capacity to conceptualise interactions to only three considerations. These are generally represented as intersecting circles and, on paper, a little doodling will show that no more than four shapes can be made to intersect each other while having a border with each of the other two, both together, and separately. This is called the four colour theorem, as yet an unproven mathematical curiosity, first put forward by Charles Dodgson who also wrote Alice in Wonderland.
However, if one adds a third dimension and conceptualises one more octopus-like tubular, plastic fifth element, touching all of them and potentially drawing on all the others, both together and separately, one can construct in plasticine, but not draw, part of the model that I am proposing.
My model of sickness consists of five concepts: disease, illness, malady, physiological event and morbidity.
All are interdependent as well as being influenced by any number of social, medical, political, economic and cultural considerations.
Physiological event, defined intuitively, is my addition. I have borrowed disease, illness and malady and the fifth, morbidity, that equates with therapeutic concern and can be measured in terms of days lost to disability and cost.
The five colour "morbus model" is not offered as a new classification, but as an arena in which opinions about the nature of health, the interrelationships of disease, illness, physiological events and maladies to each other, and to morbi and morbidity, can be scrutinised and unravelled. These are of interest to medical researchers, clinicians, sociologists, legislators, economists, biologists and others.
Clarification of our thinking here will differentiate us from those who routinely take the apparent for the real, such as judges, juries, physiotherapists, chiropractors, paramedical staff, ergonomists, and "RSI" workers. If things were always as they seemed, experts would be redundant. Ordinary people seem to know intuitively if their friends or relations are afflicted with disease or demonstrating one of the many forms of illness-like behaviour. Perhaps it is not in the interests of large segments of the practising medical profession to know the difference. Empirical therapies, currently promoted by academics who should know better, in articles on the drug treatment of illness behaviour, would have to be abandoned in favour of more rational interventions. However such knowledge might influence how future generations of doctors are educated, so they do not lose therapeutic jurisdiction over, and are able to handle more rationally, the non-disease problems that patients present.
First the definitions:
Both the terms illness and disease, in which health is generally perceived, predated scientific medicine and the identification of most of what we now classify as disease. They are often defined each in terms of the other. The needs of the discourse are better served by the attribution of standardised meanings for the terms "illness" and "disease" and these were provided by Barondess, and widely cited in journals of philosophy of medicine.
Disease may be viewed as a biological event, characterised by anatomic physiologic or biochemical changes or by some mixture of these. It is a disruption in the structure and/or function of a body part or system. It may be due to a variety of causes, may persist, advance or regress through a variety of mechanisms and may or may not be clinically apparent.
Illness, on the other hand, is not a biologic but a human event. It consists of an array of discomforts and psychosocial dislocations, resulting from interactions of a person with his environment. The environmental stimulus may be a disease but frequently it is not. (It has been estimated that 50 per cent of clinical contacts are for complaints without a definable biologic basis); It may be a stressful series of life events or a set of reactions to perceived threats which are largely symbolic.
Culver and Gert defined malady as:
"...a condition, (other than his rational belief and desire) such that he is suffering or is more likely to suffer an evil (death, pain, disability), loss of freedom or opportunity or loss of pleasure in the absence of a distinct sustaining cause."
This includes hypertension as it increases risk of heart attack or stroke, predisposition to allergy, menopause, menstruation and pregnancy. I would include congenital anomalies, diaphragmatic weakness, but exclude the women's troubles already criticised on feminist grounds by Michael Martin.
The physiological event can be defined intuitively as one experienced by most persons at some time. Physiological events would include pregnancy, childbirth, menopause, fatigue, hunger, fear, growing pains, grief, worries, ageing and the process of dying.
It is taken for granted that disease, illness, maladies and physiological events interact. How, when and why they interact to produce a morbus or measurable morbidity is the subject of concern for an expert witness in a medico legal case.
Symptoms and discomforts are a universal human experience. Most are readily recognised and dismissed by the individual as trivial. A small segment come, sooner or later, to the attention of the orthodox health care system.
Illness and disease are not congruent; indeed either may be present in the absence of the other. Illness in the absence of disease, however is congruent with the notion of "illness behaviour" or somatization.
The relationship between them is taken for granted but it is actually obscure; one recalls that some traumas and diseases are inevitably accompanied by illness. Others are not associated with illness or morbidity until it is too late. A "symptomatic psychosis" may irregularly occur with a number of physical disease entities. Does epilepsy or a brain tumour cause a psychotic illness by virtue of its position, or does it release a toxic neurotransmitter? Why does it not happen every time? Or is a symptomatic psychosis a reaction to an ill perceived threat?
I have no intention of trying to categorise the various ills that beset the human race into these or any other categories. Some categorisation would be clear, based on biological that is normative criteria, other categorisations would be evaluative. Where to place other ailments could take up a week's seminar to decide, and depends on vagaries such as the weather. To a large degree categorisation is fluid and dependent on epistemic, social, contextual and political factors, as well as on the perceptions of experts and others.
All four components of morbidity might be seen as merging into each other. The determinants of their interfaces are to be examined.
Operating alone, each might be of clinical or social consequence; under some circumstances one, two or more of them might create a morbus and become an area of clinical concern. Contemporary clinical concerns arise out of the medicalisation of fatigue, discomfort, unhappiness, anger, failure and the expected consequence of having been carpeted for bad behaviour.
Sedgwick speaks of the politicalization of medical goals and argues that
"The future belongs to illness; we are going to get more and more disease since our expectations of health are going to become more expansive and sophisticated".
There are very good reasons why we might want to know what it is that constitutes morbidity. When the need to manage decreasing resources demands rational behaviour, appropriate action can be taken to encourage doctors to spend their time, and taxpayers' money, on activities that revitalise, rather than disable, those who might otherwise cope.
Can we, for example, articulate why it is that when the national health scheme, Medibank, was first introduced, each Australian made an average of 2.2 visits each year, and now he or she attends between six or seven times. Do we know if an improvement in the nation's health has resulted from such activity?
Do we know why it was that industrial accidents fell by 30,000 in NSW in 1983, and similarly in other states and the costs of workers' compensation, reflected in premiums, went from 286 million in fiscal 1980 over the following four years to 666 million? What it suggests is that the health of the working population deteriorated. Was this morbidity measured in dollars and in time lost from work? In other countries, a push towards occupational Health and safety also resulted in the over medicalisation of occupational illness.
The Law utilises a concept of legal causation which has little if any relationship to medical causes. Legal causation leads to absurd consequences, and legitimates much irrational treatment. However judges do not consider the effects of their decisions on the practice of doctors. If doctors lack theory can we expect reason from others?
Supreme Court decisions have been taken to the effect that "functional disorder" is an injury, which in fact is precisely what it is not; that alcohol abuse, but not opiate abuse, is a disease, that a toxic delirium is a disease of mind, that attitudinal pathosis is a compensable disorder and that personality disorders and multiple sclerosis are caused by stress. In a more rational world a court might seek enlightenment as to how certain events are to be viewed in relation to others. A judge might like to know how we reach the decision concerning the end of aggravation of a disease process and the beginning of illness behaviour. Does illness behaviour have an external cause, determinants which are in the area of "wants" and "desires" or does it have meaning? Can it be viewed in a determinist framework in one jurisdiction and not in another? Why is there no consistency in social theory here? . Instead, decisions on legal causation adopt Mandelbrot's Chaos theory which predicts that a butterfly flapping its wings in South America contributes to a hurricane in Florida three months later.
Clear thinking might allow us to have an input into many situations. A person might seek to have his or her condition, say spondylolisthesis or allergy to cats defined as malady for the purpose of getting employment or for getting disability insurance. Later he might want it redefined as disease for the purpose of compensation. A law might be needed to identify those with maladies in such a way that the employer need not fear employing them, releasing subjects from the stigma of discrimination and at the same time relieving employers of responsibility for their potential handicaps.
A legislator might seek to reduce costs of insurance premiums and might ask how this can be most equitably done, with the helplessly diseased winnowed out of the unconsciously motivated ill; how the culpable employer might be separated from the blameless one, and not penalised as happens now.
The medical profession has itself to blame.
If doctors were to adopt a position which is not so medico-centric, not so reliant on medical power, not wishing for greater therapeutic jurisdiction, then the numerous problems of definition and relationship in the arena between medicine and society might be better addressed by them than by those judges, politicians, trade union officials, lawyers and legislators, who now resolve them now in the absence of understanding.