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Physicians, Patients, and Disease:
The Consequences of Conceptualization

Introduction

In the previous chapter whether mental illness is a myth was discussed from a theoretical and conceptual perspective. The conclusion was that psychiatric disorders can be considered diseases but that their status as such is different from that of physical diseases mainly in the way they are validated and explained.

This chapter will include a continuation of the comparison between the biomedical and biopsychosocial disease concepts, this time, however, focusing on the dramatis personae: physicians, patients, and others. The effects of these disease concepts in practice will be central to the discussion. That is a relevant matter regarding the conceptualization, as a concept, like a theory, exists by the grace of its applicability, utility, and efficacy.

In psychiatry, roughly speaking, two types of explanation are common: the causal-analytic explanation and the sense-analytic or hermeneutical explanation. In the former the explanation of phenomena is sought in cause-effect relationships as in somatic medicine. This type of explanation is applied in particular when organic aberrations, heredity, or constitution are involved in the disorder. Hermeneutical explanations seek to explain the significance of being ill. The motive for being ill, what it expresses, and the purpose of the illness are investigated. The sense of experience and behavior are examined. In the causal-analytical domain laws of cause and effect limit human freedom. In the hermeneutical domain freedom, responsibility, and their restriction by non-causal factors are relevant concepts. The line between these two domains has been a matter for philosophical, moral and political strife for centuries. I do not intend to join this strife. My point is that in psychiatry, causal-analytical and hermeneutical explanations are two complementary ways of viewing being ill. As causal-analytical explanations suit the biomedical disease concept, and are in fact identical to the way illness is viewed in the biomedical disease concept, I can leave that part of psychiatry out here, and discuss it under the header of the biomedical disease concept. This is not a choice based on principle or a proposal for reclassification, as Szasz proposes, but rather a practical measure intended only to simplify the argumentation by avoiding the necessity of constantly repeating, “In psychiatry, inasmuch as causal-analytical explanations are applicable, the same holds true as in somatic medicine.” So this chapter will deal only with the part of psychiatry in which hermeneutical explanations for being ill are considered valid.

Perhaps it is a good idea to briefly summarize the relevant differences between the biomedical and biopsychosocial disease concepts here:
  1. The biomedical disease concept is more narrowly defined than the biopsychosocial disease concept. It assumes that illness is an event that affects the body. It is based on physics, chemistry, and biology. The biopsychosocial disease concept is broader. It is based on the premise that man is a system composed of several subsystems and is a part of several super-systems. It is based on psychology and sociology in addition to chemistry, physics, and biology.
  2. The biomedical disease concept uses causal-analytical explanations, mainly cause-effect relationships. The biopsychosocial disease concept also uses hermeneutical explanations.
  3. In the biomedical disease concept behavior is viewed as an objective symptom or syndrome and explained as the effect of certain causes. In the biopsychosocial disease concept behavior is also viewed as actions with motives and intentions.
  4. Within the biomedical disease concept therapy is the attempt to correct an aberrant physicochemical pattern. Within the biopsychosocial disease concept therapy is the attempt to correct system features at different levels.

Several problems can be expected when comparing both disease concepts in practice. The first problem is that the biomedical disease concept, after having been formulated in the nineteenth century, has extensively functioned as medical paradigm without being significantly challenged. Of late – Kendell states that as from 1960 – it has been increasingly criticized. It seems to me that there is confusion nowadays. Many people still maintain the biomedical disease concept. Many other people are seeking new conceptualizations because the old one does not suffice. Its deficiency has possibly become manifest partly because the biomedical disease concept increasingly shaped medical practice. Attention was monopolized more and more by the aspects of disease that can be approached and influenced through technologically. So much focus was directed at organic aberrations that illnesses and ill people themselves were pushed to the background. Seeking and designing new disease concepts can be considered a reaction to this development and to the realization that such a shift towards organic aberration is not possible regarding some diseases because it cannot be found. The current confusion may well be comparable to a conflict of paradigms as described by Kuhn in which the forces that would have us return to the older paradigm, of which Szasz is a powerful advocate, and the forces which due to the shortcomings of the older paradigm seek new concepts, together contribute to the current image.

The second problem is that in psychiatry (and also in general and family medicine) a much broader disease concept than the biomedical one has been standard for a long time already. Yet this much wider view of what being ill is seems to disappear as soon as the disease concept itself becomes the subject of scrutiny in psychiatry. In other words, a different disease concept is claimed to be held than is actually held. An example is the statement that psychiatric disorders are diseases just like physical illnesses. If such a statement were taken seriously most psychiatric disorders, namely those in the hermeneutical domain, would go up in smoke. That is not happening. Something much more dangerous is happening, namely, that psychiatric disorders are being treated as though they were identical to diseases involving physical aberrations and thus as though causal-analytical theories of explanation were valid in the hermeneutical domain as well. There is no reason not to test causal-analytical theories in psychiatry but when they (and only they) are treated as valid without examining whether the premise on which they are based is valid, explanatory models in the physical sciences may as well be declared valid in the humanities. Adhering to a biomedical disease concept invites us to do so because declaring a disease concept applicable is not a value-free theoretical-conceptual event but generates consequences for physicians, patients, and others. By that I mean that all sorts of people benefit from declaring something to be a disease. That is the subject of this chapter.

A third problem is that it is not only the conceptualization itself that determines events although its influence is far-reaching. Bockel et al researched the connection between illness behaviors and disease careers of an out-patient population and the influence exerted on them by family doctors. They conclude, “Wesentlicher Einfluss auf die Krankengeschichte und das Krankenverhalten kommt dem Krankheitskonzept zu.” [“Essentially behavior and the course of the disease is influenced by the disease concept.”] However, although within a biomedical disease concept there can only be illness when there is a demonstrable physical aberration, there is plenty of room in the etiology and pathology of the disorder for psychical, social, and all other sorts of factors as well. Not only that but there is a medical ethic – beyond this concept – which contributes to determining physicians’ behavior. That is to say that the beside manner is not anchored in the concept yet remains significant. The difference is that in the biopsychosocial disease concept the bedside manner is considered part of the treatment and relevant to the disease itself, to its course, and to the (results of the) treatment. Engel provides us with a good example. A man is lying in a hospital attached to a monitor after a heart attack. Two physicians are trying to perform an arterial puncture, but fail. They are naturally dissatisfied with this. The patient is becoming continually more anxious and after several minutes he has ventricle fibrillation. The physicians exclaim how fortunate he is that the fibrillation did not start until after the patient was attached to the monitor, overlooking the fact that the fibrillation may have been (in part) caused by the tension created by the physicians’ failed puncture.

This can be formulated another way. A humane, understanding bedside manner is not essential for the course of illness and recovery in the biomedical disease concept. That does not mean that it is totally unimportant. It certainly counts in an interpersonal way. It is comparable to the service at a restaurant: it is important but has nothing to do with the quality of the food served. At the same time everybody knows that even the most delicious food will be less tasty if served in a brutish manner. If this is true, the implication is that the food itself together with the way it is served, and possibly additional factors, determine its flavor. This last way of reasoning, employing all sorts of factors, is precisely the hallmark of the biopsychosocial disease concept. Here is a recent example with regard to health care in the Netherlands. No so long ago it was announced that a certain fixed length of stay in the hospital was determined for various operations. Such a measure can only be conceived within a biomedical disease concept. Disease is a bodily aberration. The operation is a technical matter which takes a fixed amount of time and is thus directly comparable with the reparation of a machine. Duistermaat, in an excellent article, states, “And yet it must be possible to give the patient responsibility as well in the hospital. After all, he is the expert on his own body. The question, ‘Do you feel up to being operated in the morning?’ compels a person to focus on his own body and gives him a say in it.” That is not only a different type of bedside manner. It is also utilizing a different disease concept.

Below I will continue the comparison between the biomedical and biopsychosocial disease concepts firstly by considering the biomedical concept a territorial concept, meaning that it marks a territory and its boundaries, namely, physicians’ (2). After that I will focus on the physician and his functioning, specifically, on his different roles. Although at times I will discuss physicians in general, my intention is to shed light on psychiatrists and their professional activities (3). Next I will discuss how Szasz views the psychiatric patient, who, according to him, should not be a patient, so the psychiatric patient and the biomedical disease concept (4). Then the psychiatrist-patient relationship will be examined (5). The chapter will be closed with the formulation of several conclusions (6).
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