Conclusion

Many health professionals continue to define disease and health simply in terms of each other. This school of thought contends that the two are on a spectrum, their extremes - serious disease and excellent health-being at opposite ends. There is a heuristic value in this viewpoint, but it poses serious problems in the real world of medical practice. The problems are related in part to medicine's ability to fix points on the spectrum of disease more discretely than in the region of health. When patients tell health professionals that they are "not quite up to par" or are feeling "very sick," there are often objective means for translating these expressions into useful information. Beyond this, the concept of illness has reasonably finite points on the spectrum. At its extreme, hospitalized patients are classified as serious, critical, very critical, and, ultimately, deceased.

Even though the concept of relative health can be traced to the ancient Greeks, the spectrum of health (as opposed to illness) has no such clear points or distinctions (Kudlien 1973). Patients may state that they feel very good or are in excellent or perfect health, but even if there is a reason to objectify their assessments, there are no logical or technological tools for performing the task. If the examination and laboratory results are normal, a patient will generally be classified simply as healthy. Any qualification of a statement about health, such as "almost healthy," moves the patient to a point on the spectrum that coincides with slightly impaired or ill. A measure of the difficulties here is seen in one author's suggestion, then rejection, of the idea that health could be quantified by fixing a point on the scale and allowing health to be two standard deviations from the norm (Caplan et al. 1981).

One reason for this state of affairs is that, from the standpoint of time, health is on a generally unidirectional spectrum directed toward illness and death. Things are a bit more complicated than the old saw "We are all dying from the moment of conception," but the element of truth in looking at human existence in this way may help us understand why health and disease are not au fond a tension or balance. True, for many years we may be in the healthy range of the spectrum, but during this time, our unidirectional genetic program (as best we now understand it) is moving us inexorably toward disease. True, also, in a given illness episode, we may reverse the direction and return to the spectrum of subjective and objective health, but this turnabout is temporary. The key element, time, remains unidirec tional. Even as we move out of a given illness to health, we are advancing toward death, much as we are both gaining and losing ground as we walk against the direction of a moving sidewalk.

In desperation someone once defined disease as something people go to doctors for. As simplistic as this seems, and as unsatisfying as it may be to medical historians and philosophers, there is more than a germ of truth in the definition. Indeed, it reminds us of the original meaning of our elusive term - disease. It covers situations in which the "patient" is simply ill at ease, without regard to the finer nuances of normality and impediment. Originally the word had no connection to pathological conditions, so that one might be said to be reluctant to dis-ease oneself by attending a lecture on changing concepts of disease (Garrison 1966).

The older definition of dis-ease applies to much of what physicians do nowadays. The young graduate student is dis-eased by a pregnancy that threatens to disrupt her academic career. The ensuing elective abortion relieves her dis-ease, but it is difficult to fit a normal pregnancy into any system of illness-disease considered so far. Some might contend that the student suffers an impediment, and in career terms, that might be true. But we would seem to be headed for even murkier depths if we translated into disease the impediment occasioned by a physiological alteration so profoundly normal that the species would die out in its absence.

Many encounters between patients and physicians result from similar social and cultural pressures. The middle-aged executive who resorts to plastic surgery to eliminate his perfectly normal, and even honorable, facial wrinkles is dis-eased, as are most who undergo cosmetic surgery. And, of course, the vast majority of persons seeking psychotherapy are dis-eased, in that it is basic to human existence to experience anxiety, insecurity, loneliness, and even depression. Certainly when physicians treat persons whose complaint is not only diagnosed as normal, but almost universal, dis-ease in the older sense must be involved rather than disease as it has been analyzed in the ontological or physiological meanings.

It is properly humbling to attempt to summarize an essay that one realizes has not succeeded completely in its aim. Under these circumstances, the temptation is to suggest that the question being asked is not a proper one in the sense that it cannot be answered by logic or experiment. Indeed, one of the more cogent summaries of our conundrum was expressed in precisely these terms by Owsei Temkin:

The question: does disease exist or are there only sick persons? is an abstract one and, in that form, does not allow a meaningful answer. Disease is not simply either the one or the other. Rather it will be thought of as the circumstances require. The circumstances are represented by the patient, the physician, the public health man, the medical scientist, the pharmaceutical industry, society at large, and last but not least the disease itself. For our thinking about disease is not only influenced by internal and external factors, it is also determined by the disease situation in which we find ourselves. (Temkin 1977)

Claude Bernard (1865) held that seeking the cause of life or the essence of disease was wasting time in "pursuing a phantom. The words life, death, health, disease, have no objective reality." Here Bernard was only partly right. It is not a waste of time to struggle with these definitions. There is much to be gained if the task does nothing more than force society, and especially medical people, to think of the consequences each time they use words to describe disease and health. The process is a waste of time only if one enters into it with the exclusive goal of arriving at universal and timeless definitions.

Robert P. Hudson

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