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The Biomedical Disease Concept as a Territorial Concept

By its nature the biomedical disease concept is a concept that can be understood and applied exclusively by experts. Due to the strong technological development in medicine an enormous package of knowledge and skills is now essential within this disease concept. This package is only understandable and available to insiders who are trained in it and have learned to understand the “secret language.” The epitome of the insider is the physician. This can be formulated in two ways. Physicians’ domain is disease, but also, physicians own the domain of disease. The term domain suggests that not only is this a matter of effective conceptualization in a scientific and practical sense but also that there are territorial claims. The disease concept has also become a territorial concept. The point is not even whether doctors (or other professionals) have certain capabilities but whether it ipso facto means that others do not belong in that territory and must be refused. For instance, in “Mental Illness is a Myth” Szasz states that a large part of human behavior has been psychiatrized and “in so doing, the study of a large part of human behavior is subtly transferred from ethics to psychiatry, from the free marketplace of ideas to the closed wards of the mental hospital.”

This territorial claim cannot be wholly explained by the specific expertise required. Formerly magicians, medicine men, and priests had territorial claims as well though they were not based on science or qualification, but rather on being initiated into mystical secrets and supernatural powers. Mostly, though, their claims were based on the position of power which they had attained.

In modern times such a territorial claim rises from a combination of having a specific qualification and a certain monopolistic position indicated by the term professionalization. Disease is the domain of the medical vocation. Obviously this leads to a totally different description of the biomedical disease concept than used until now. Aside from a theoretical and scientific concept it is now also describable as a social institution that has led to professionalization in a certain vocation, has become this profession’s territory, and partly shaped the institutions and services for tracing, diagnosing, and treating diseases.

This position wants further explanation. It cannot necessarily be taken for granted that professionalization of a certain vocation is linked to the development of a concept. Blaney emphasizes that the professional implications of the “medical model” are completely independent of its utility as a conceptual instrument. “The confounding of these two issues reaches a high level of folly when the statement ‘mental disorder is disease’ is used as a euphemism for ‘mental disorders are the province of persons with an M.D.’ Whether or not either of these statements is true, they do not imply each other.”

It is worthwhile to investigate whether Blaney’s postulation is tenable in practice. I will attempt to do so first by examining the influence of the biomedical disease concept on the relationship between physicians and patients and on “lay people” in general, and afterwards whether and to what extent the relationship between the medical profession and other vocations is determined by this territorial aspect.

When physicians employ the biomedical disease concept they consider illness an event describable in physicochemical terms. The causes, course, and treatment are formulated in terms of physicochemical influences. Patients can talk about their illnesses almost exclusively in terms of experience (pain, anxiety, dizziness, etc.) and behavior. Exaggerating somewhat we can put it this way: Physicians ask patients about their complaints in order to gain a general idea of the direction in which they should be thinking. Which aberrations might there be and where? Afterwards they and their patients part ways. The physicians continue their inquiries into the patients’ body (parts). Results of the physicians’ examinations are expressed by prescriptions or other treatments or by additional examinations, the purpose and significance of which are often difficult to explain. Patients may try to understand when matters are explained to them in simplified terms. They can scarcely or not at all participate in the discussion. Only physicians are knowledgeable in the domain of disease, only they speak the language, nobody else. Other professionals do not, other people involved with patients do not, and last but not least, patients do not.

Even though from a theoretical and scientific aspect the biomedical disease concept is valuable, it has serious drawbacks as a concept in treating patients. Illness and being ill are realities in everybody’s life. So knowledge and insight are also important to everybody, not only for preventing illness and identifying it on time, but also and especially to be able to understand what is happening, what the dangers, risks, and possibilities are in a certain situation. Disease, when understood as a physicochemical concept, makes it possible only to inform patients in technical jargon which is hardly comprehensible to lay people, let alone manageable. Information, dialogue with patients, and the method of discussion themselves are strictly speaking outside the domain of what is considered relevant regarding disease. Disease is defined precisely in terms that eliminate those aspects that would make it possible for patients to comprehend and manage what is wrong with them. (See chapter V, 2.2.)

This attitude on the part of physicians has several implications of which I will mention the following:
  • Physicians consider their patients’ diseases as a matter of and for the professional. Reporting back to patients what is going on and what must be done is of secondary importance. Although most physicians are convinced of the will to live, recuperate, and thus cooperate, these notions are not included in the biomedical disease concept because they cannot be translated into physicochemical terms. This can contribute to patients’ feelings of anxiety and insecurity. Patients may feel like a number, like their doctor does not give them the time of day. That is only partly true. Patients’ bodies have physicians’ full attention. Only they as people are not or scarcely noticed.
  • Physicians consider the results and documentation of examinations as their own property or that of the clinic in which they are employed. The idea that someone might want to obtain x-ray photographs of his own organs not too long ago stirred up surprise and consternation in the Netherlands.
  • Physicians consider the facts that they collect, the stories from and about their patients, as their property, or the clinic’s. They save it not for their patients but for their patients’ benefit. The information contained in them is incomprehensible to the patients anyway and probably harmful to them. On the other hand, when patients return for treatment previously collected information can be significantly useful to their doctors.
  • The relationship between physicians and patients is basically determined by the positions of professionals and lay people, the positions of helpers and the helpless. The inescapable conclusion is that patients are dependent on their physicians.
  • Mahler points out that it is medical technology itself that determines on what the funds available for health care will be spent. All technically possible treatments must be available. He adds that this may have consequences that do not go without saying from a moral perspective. “In some places where it has been examined it has been identified as an increasing expenditure upon persons in the final months or years before death. It appears that this expenditure does not measurably increase life expectancy or make humanly tolerable the closing episodes of the lives of elderly people.”
These implications and in particular the protests against them have become especially significant in recent decades. The protest reflects dissatisfaction among people who are and were being medically treated with physicians’ paternalistic behavior and inadequate dialogue between physicians and patients. Querido’s proposal made in 1955 can be considered a reaction to the much too narrow and therefore ineffective boundaries of the biomedical disease concept. He advocated employing professionals such as medically trained psychologists or psychologically trained medics or others, in addition to organ specialists, in order to integrate the somatic, psychological, and social factors. His conclusion that we need a new type of family doctor who should integrate the somatic, psychical, and social factors, has been reflected in family medicine. So the new type of family doctor also no longer bases his practice solely on the biomedical concept.

I pause here to point out a most peculiar and interesting position that Szasz takes in this respect. Szasz declares mental illness to be a myth among other reasons because the concept of mental illness conceals people’s true problems in living and makes them unrecognizable. (See Chapter I, 4.2.) Patients are turned into victims of illness who are dependent on experts, namely psychiatrists, for solutions to their problems. This process of dependence on physicians however began much earlier and has become much broader and deeper due to the nature of the biomedical disease concept which creates this dependency. Szasz, considering his preoccupation with autonomy, could be expected to be hostile precisely to this biomedical disease concept. Yet he but asserts that the development of our culture has made extensive specialization inescapable. Querido agrees with this, although he sought a solution for the dilemma by linking the above-mentioned (super) specialists as “generalists” to the new type of family doctor.

Zola posits regarding this that the process of “medicalization,” that is the process by which concepts of sick and well are considered relevant to increasingly many matters, must not be blamed so much, and certainly not in the first place, on psychiatry. He ascribes this process to “our increasingly complex technological and bureaucratic system – a system which has led us down the path of the reluctant reliance on the expert.” Zola does admit that psychiatry and preventive medicine in particular have spectacularly contributed to medicalization. Illich extensively and passionately points out how the biomedical disease concept causes dependence and the dangers thereof.

My conclusion is that Szasz sees the “smaller” evil, namely the threat to autonomy caused by medicalizing behavior, but that he scarcely notices the “larger” evil of the medical disease concept causing dependence on medicine in general.

Now I continue the thread of my argumentation. Blaney’s postulation which is that disease concepts and professionalization are unrelated was examined in view of the influences of the biomedical disease concept on the relationship between physicians and “lay” people. It was found that in the biomedical disease concept illness becomes physicians’ territory, and nobody else’s. Now I will investigate to what extent professional relationships between physicians and other helping professionals are determined by territorial aspects.

First I present some quotes directed at psychiatry. To illustrate the assertion that “the domain of disease is physicians’ property” I will mention Kendell. He states, “By all means, let us [psychiatrists] insist that schizophrenia is an illness, and that we are better equipped to understand and treat it than anyone else.” To illustrate the assertion that “physicians’ domain is disease” I offer the statement by Wolffers, quoted by Grauenkamp that “hyperventilating patients do not belong to physicians’ work domain because these patients are not sick.” (my italics – J.P.)

Ribner wonders why psychiatrists are so reluctant to work in Community Mental Health Centers. He quotes Du Mas, a clinical psychologist, who says “Generally speaking, M.D.s certified in psychiatry are the people most competent to treat mental illness. By law and training, they are the only ones qualified to treat the whole person: with drugs, organically, surgically, psychologically, and socially.”

Next Ribner paraphrases Fink. “Fink goes on to answer his own questions by maintaining the superiority of psychiatric training and the value of the medical model. He acknowledges that a problem may exist around who should be team leader. But he concludes that the psychiatrist alone possesses the ‘depth of understanding’ and the ‘capacity for a broad overview of the entire process of illness and care’ to make clinical judgments.”

Glasscote is the third to be mentioned by Ribner. “To those positive attributes of the medical model, Glasscote adds two not usually considered – thoroughness of care and conservatism. It is, he says, the psychiatrist who will contribute these qualities, implying that no one else can offer the first and no one else wants to offer the second.”

Afterwards Ribner quotes Zusman and Lamb, “Psychiatrists must become more involved in community mental health and should reassert their leadership. As the group of mental health professionals with both the broadest and most intense training in relevant areas, they have an unmatched over-all perspective.”

Ribner quotes the official position of the American Psychiatric Association. “The medical, including psychiatric, treatment program offered by a Community Mental Health Center must be the responsibility of a physician, preferably a psychiatrist, and should be directed by him. The Center’s total program, however, may be under the administrative direction of any health professional who has adequate training in administration and experience in mental health.”

In contrast, Ribner quotes Eisenthal and Bloom who posit that psychiatrists keep to the medical model for the sake of safety, and not because of conviction. “The physician is defending a model in which his superiority is secure.” This rounds up Ribners quotes.

Roman defines medicalization as a social process with two elements. The first is that a certain complex of behaviors fits into a medical model. The second is that the accompanying intervention is to be carried out under medical supervision. Berlin et al agree.

In addition to these statements it should be noted that certain areas in medicine such as surgery, the prescription of most drugs, and physical examinations, is permitted only to physicians in most states. The legal rules and regulations may be considered a stamp of approval on the territorial claims and convert them to an exclusive right.

On the basis of the above I conclude that Blaney’s postulation, namely that the disease concept and professionalization are unrelated, is untenable. The biomedical disease concept has double significance. It is both a theoretical and scientific concept that aims to examine and influence disease phenomena as well as a social institution that led to physicians’ professionalization. So all literature about disease as a biomedical concept should be read in two ways: first as studies on the conceptualization of disease as a theoretical problem and secondly as studies on physicians’ domain. Each implies the other.

In the same way the process of medicalization constantly raises the question whether new relevant associations are being made or whether the medical profession is engaging in expanding its territory. The advancement of ideas about disease as a medical paradigm is complicated by all sorts of professional interests contributing to the discussion from the background. Here is another quote to illustrate this. Sarason et al quote Albee (a psychologist), as follows. “We must abandon the illness model and develop a viable alternative model. Clinical psychology cannot be both an independent profession and a health profession. So long as we acquiesce to the fiction that people with neurotic and psychotic behavioral disturbances are sick, our field will keep itself in bondage.”

Compared to the biomedical disease concept the biopsychosocial disease concept seems to have very important advantages. Not only do physicochemical and biological categories fit into this disease concept, but so do intrapsychical, relational, social, and cultural categories as well. This fact alone already implies that territorial claims within the disease concept are extremely difficult to maintain. Nonetheless applying a reduced concept in certain situations remains relevant as well as posing territorial requirements regarding training and qualification of those who, for instance, perform operations. In other situations this concept will invite, and even compel, cooperation between different disciplines. Not only that, it replaces exclusive explanations within the biomedical concept with various explanations and explanatory models which are in principle of equal value.

In family medicine and psychiatry, which involve all of these categories, such a development has been going on for decades in the Netherlands and elsewhere. Exactly because physicians cannot maintain that they are experts in so many fields respect for other professionals is facilitated, as well as recognition of their superior expertise in some of these fields.

Finally, the biopsychosocial disease concept has the essential difference that patients comprehend and so can and must also participate in discussing prime aspects of illness and being ill. The significance of “switching” from a biomedical to a biopsychosocial disease concept to psychiatrists is stepping back from a position in which they were lord and master in their “domain,” and sharing this domain with various others. This changed situation generates tensions for psychiatrists as well as for others which are not easily solved. For instance, the question of what exactly of all the issues raised in team discussions should be considered medical remains confusing and controversial, not in the least because it remains totally unclear which disease concept is being maintained.

To date there is no consensus about the ideal position of psychiatrists in multi-disciplinary treatment teams. Psychiatrists often emphasize their distinction from other team members by the breadth of their expertise rather than by its depth. That would be an argument for viewing psychiatrists as coordinators and ultimately responsible for the team as also suggested in some of the above quotes. Their broad expertise makes them suitable for supervision and coordinating interventions. Their leadership skills seem, however, to depend in particular on their personal qualities, qualities that are not identical to psychiatric qualification.
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