Mary Ann Gardell Cutter

Value Presuppositions of Diagnosis: A Case Study in Diagnosing Cervical Cancer

Through diagnosis a clinician approaches disorders by applying an explanatory account that allows the patient to be cast in a clinical category and therapy role. Because diagnosis usually involves understanding and undertaking clinical problems through pathoanatomical and pathophysiological frameworks, clinical diagnosis is theory-ladened. Diagnosis also involves judgments about the worthiness of particular conditions for special attention. These judgments involve evaluative considerations, and turn in part on accepted norms of scientific investigation and therapeutic success. As a result, diagnosis is pursued not solely for its own sake, but also for the sake of satisfying certain evaluative frameworks. In other words, clinicians seek to know well, as opposed to simply knowing truly the character of clinical problems. In short, diagnosis is contextual and intervention-oriented.

The Nature of Disease

This chapter explores the metaphysics of disease, with emphasis on the ways in which concepts of disease reflect what we know in medicine. It considers traditional discussions in the philosophy and history of medicine about the nature of disease, with particular attention to its structure and development. It argues that competing accounts of the nature of disease offer limited yet complementary ways to understand the metaphysical character of disease, thereby resulting in what is called a limited realist approach. As Khushf (1995, p. 465) rightly notes, coming to terms with the tensions between and among diverse ways of conceptualizing disease is perhaps one of medicine’s important goals as it moves into the Third Millennium, a time that promises great strides in our understanding and control of disease1.

Negotiating criteria and setting limits: The case of aids

The classification of clinical problems, such as AIDS, requires choices. Choices are made on epistemic (i.e., knowledge-based) and non-epistemic (i.e., action-based) grounds. That is, the ways in which we classify clinical problems, such as AIDS, involve a balancing of different understandings of clinical reality and of clinical values among participants of the clinical community. On this view, the interplay between epistemic and non-epistemic interests occurs within the embrace of particular clinical contexts.The ways in which we classify AIDS is the topic of this paper. We consider the extent to which we construct clinical reality; we examine a suggested classification of AIDS; and we conclude suggesting that the choice regarding how to classify AIDS is the result of negotiation among participants in the clinical community.

Disease, Bioethics, and Philosophy of Medicine: The Contributions of H. Tristram Engelhardt, Jr.

In this essay, and in honor of physician-philosopher H. Tristram Engelhardt, Jr.’s contributions to bioethics and philosophy of medicine, I argue that what makes Engelhardt’s body of work notable in the history of philosophy is his recognition that medical concepts, such as disease and health, illustrate the dependence of bioethics and philosophy of medicine on each other. In what follows, I review Engelhardt’s analysis of disease in terms of its descriptive, explanatory, evaluative, and social dimensions. I show how the concept of disease carries bioethical implications, and such bioethical implications are framed in terms of ontological and epistemological considerations made explicit in the philosophy of medicine, thus highlighting the reliance of bioethics on philosophy of medicine, and vice versa.

Concepts of Genetic Disease

The Human Genome Project (HGP) has spawned a tremendous explosion in research in genetic science and medicine. A major impact of the HGP will be an evolution in the way we think about disease and normal physiology. What follows is an analysis of the concept of genetic disease, in light of the analysis that has taken place in this work, particularly in Chapters 3, 4, and 5. In this way, the analysis in this chapter carries out the lessons of this work by considering the nature of disease--in this case genetic disease--and how we know it, and how it reflects what and how we value. It illustrates how this work has application in current debates.

The Context of Disease

One of the difficulties of writing about disease is that our understanding of disease changes with time. We tend to think of the scientific core of medicine as unchanging. Medicine, as a science, speaks about what is, not about what may be for the moment but inevitably will change. However, much has been made recently of the changing character of medicine and science. As the contributions of Ludwik Fleck (1979 [1935]) and Thomas Kuhn (1970 [1962]) to the history and philosophy of science and of medicine have shown, there are no such things as neutral, naked, and bare facts. Facts always appear interpreted within the embrace of theoretical frameworks, whether or not these frameworks are formally or informally developed as scientific accounts. In addition, they are always given in a particular socio-historical context. There is no timeless or contextless account of reality, including disease, or at least there is no such interpretation available to humans. This chapter argues that disease is contextual. In so doing, it explores the character of contextualism in medicine, why contextualism is not relativism, and how conflicts among competing interpretations of disease may be resolved. In the end, a localized account of disease is offered.

Concepts of Gendered Disease

Much has been said in the latter part of the twentieth century about the importance of addressing more closely women’s disease and health. Discussions have led to an increase of women physicians, women’s health care centers, and the involvement of women in clinical research projects. The call is for more attention on women’s disease and health in order to better serve women. In other words, we are called to pay closer attention to how gender frames disease. This chapter takes a closer look at the role gender plays in the construction of disease, thereby drawing upon the analysis provided earlier on the social construction of disease, particularly Chapters 6, 7, and 8. It argues that a non-neutral, or rather a non-gender-neutral, account of disease is non-defensible. The task, then, is to determine the kind, level, or degree of gender bias in the framing of women’s disease that is appropriate for judgment and action.

Knowing and Treating Disease

Clinical medicine is an applied science. It is the search for explanation and prediction in the service of practical goals, e.g., the achievement of well-being and the avoidance of impairments. Since one is interested in applying knowledge, the success of such applications is judged primarily by practical standards. Disease concepts involve a complex interplay between two major goals: (1) to know clinical reality, and (2) to alleviate pain and suffering and to prevent premature death and disability. Clinicians wish to establish through concepts of disease the regularities of occurrences among clinical phenomena and to find enlightening and useful models to account for these regularities. In this way, clinicians function as medical scientists seeking to know the world. Ingredient to the task of knowing disease are judgments concerning how to alleviate pain and suffering. As this chapter shows, such judgments are complex and varied. Theory and practice are two aspects of human endeavor that clinicians’ intellectual interests sustain.

A Geography of Values in Disease

As Chapters 5 and 6 illustrate, coming to terms with clinical reality is never a purely theoretical endeavor. It is a form of action, which involves diverse modes of intervention and value judgments. In studying the role values play in disease concepts, we are reminded once again that disease is complex. This chapter investigates the ways in which disease reflects what and how we value. Put another way, it investigates the process of valuing, as opposed to the previous chapter’s emphasis on the nature of values. It sets forth a geography of prominent values that frame our understanding of disease.

The Development of Disease: The Case of Aids

Acquired Immunodeficiency Syndrome (AIDS) provides the basis for our initial reflections on the character of disease. It is a relatively familiar clinical phenomenon, much has been written about it, and our understanding of AIDS has changed dramatically in the span of almost two decades (1980–2000), from viewing AIDS as a syndrome to viewing it as a disease in its own right. This chapter takes advantage of this “discovery” and makes three points. First, the more one advances in the process of accounting for disease, the more one deals with entities that are human constructions of thought expressing certain recognizable observables in nature. As an illustration, the first part of this chapter discusses ways in which contemporary medicine has successfully explained AIDS in terms of a syndrome, an etiological agent, and a model (Cutter, 1988). Second, disease explanations seek knowledge for the sake of action. On this, the second section explores how the epistemic (i.e., knowledge-gathering) and non-epistemic (i.e., action-oriented) concerns of disease interact in how we explain AIDS. As one way to link the first two points, the third section discusses the role negotiation plays in fashioning clinical explanation by examining the ways in which socio-cultural forces shape our understanding of AIDS. In short, the movement through the explanatory levels of disease reflects medicine’s effort to understand and to be able to control disease in ways that will facilitate their resolution within particular socio-cultural settings. The following is offered as a way to set the stage for a detailed analysis of disease that takes place in subsequent chapters.