In this paper, I will discuss the notion that disease involves both evaluative and value judgements. The concept of disease is neither merely scientific or exclusively based upon societies’ values, but rather a mixture of the two. This approach helps to explain underlying biological malfunction, if any is known, as well as the implications of the effects of society, both of which work in melody to explain the sometimes convoluted, ambiguous nature of disease and disorder. Not only are both factors important to the physicians, caretakers, and researchers today, but to the patients due to insurance coverage, societal standing, mental well-being, research funding, and a plethora of other factors. Thus, arguing that disease is defined by one of the factors alone ignores the reality of how illness is looked at, treated, and understood in the modern era. The first argument that I will use to support my claim is Wakefield’s hybrid approach to disorder. Then, I will discuss an objection to my claim: that disease does not involve value judgments, with Robert Wachbroit’s Concepts of Normality. Lastly, I will rebuke these points to further defend the critical involvement of value judgements in the concept of disease.
Value judgements are woven into the concept of disease due to society’s influence. The umbrella term “disease” and “disorder” are continuously expanding in their definitions based on societal changes, medical and scientific discovery, and the progression of healthcare. A look back in history easily demonstrates the heavy role value judgements have made in diagnoses. For example, the psychodiagnostic offenses of drapetomania, the once legitimate illness coined by slave owners for slaves who wanted to or did run away, and homosexuality, which was listed as a mental illness in the DSM until 1973, are clear cut examples of values held by society at the time influencing positions surrounding health and illness. To say that the notion of disease does not include value judgements would not only be incorrect, but also limiting in how disease is addressed. To support my argument, I will briefly examine Jerome C. Wakefield’s discussion in The Concept of Mental Disorder. Wakefield holds the belief that disorder is defined as harmful dysfunction, terminology that blends together value and scientific judgements. Harm is a value term based on social norms. Dysfunction is defined in literature as “the failure of…mechanisms to perform evolutionary function.” Neither one is sufficient on their own in explaining disorder. Including value judgements to the partial definition of biological dysfunction or lesion eliminates innocuous abnormal anatomical variations, such as fused toes or the reversal of the heart’s position. Thomas Szasz, a ground-breaking psychiatrist, is famous for claiming mental illness does not exist. Skeptics like Szasz, who primarily base disease on evaluative ideas, thought that mental illness was characterized by physical brain lesions, or notable deviations in anatomical structure. For this reason, mental illness should be given the respective, and more accurate, label of brain disorders. That which could not be explained by lesion was simply socially disapproved behavior. Wakefield rebukes this argument due to existence of physical disorders that do not present anatomical lesions, such as trigeminal neuralgia. Another argument from skeptics of mental illness was that psychodiagnosis provided patients with negative social stigma. However, it can be contended that physical disease also carries negative social stigma like sexual transmitted diseases. In the Wakefield reading, the diagnostic process is touched upon. The role of the clinician, in my opinion, is to determine if the patient is suffering from one of thousands of diseases, or possibly a non-pathological issue. The clinician is forced to use value judgements in accordance with their scientific training to determine the cause of the problem. Healthcare workers from varying cultural and societal backgrounds tend to differ in their preferred method practice, which can then affect the patient’s treatment plan. As Wakefield says, “the possibility of error is explained in a functional approach; the diagnostician can simply have an incorrect belief about what a mechanism was naturally designed to do.” This is yet another way that value judgements held by society are ingrained into the handling of disorder.
Robert Wachbroit might disagree with my argument that notions of disease are heavily influenced by value judgements. He strongly believes that normality can be explained in a myriad of facets, all evaluative. The three that he touches upon are statistical, evaluative, and biological normalities, which he argues are each distinct. He equates normality in this case to function. Unlike other definitions or misconceptions, norm does not mean average, ideal, all, most, or even a particular. Normality is functionality. Wachbroit writes about sickle cell anemia and heterozygosity to explain his point. He acknowledges that the mutation in the heterozygotes performs a specific function as a protectant against malaria. Explained with goal and etiology theory, which Wachbroit presents earlier in his discussion, the gene performs a function and the function contributes to the organism’s overall goal of survival. The defense is that the immunological aspect of the disease has a beneficial function, but the hematological point of view is sickle gene is a malfunction since red blood cell production is intercepted. This seems like a weak and hypocritical argument. Evolution is contingent upon genetic variation. The ability for heterozygous individuals to survive against malaria increases their fitness, which in return makes their genes more abundant within the population and biologically ‘normal’ due to the gene’s proven functionality. Wachbroit writes that “the function of an item is its contribution to the evolutionary fitness of the organism…” This clearly renders that while evaluative judgements consider sickle cell anemia a disease due to its biological deviance from normality, the gene functions to contribute to evolutionary fitness of the heterozygous individuals, supporting the idea that the sickle gene may be considered biologically normal. However, if a person outside of a malaria-stricken geography has the sickle gene, I agree with Wachbroit in that the gene has no function towards survival and the chances of it afflicting the individual’s offspring makes the gene a biology malfunction and disease. Nonetheless, this contradicts Wachbroit’s point that cultural and societal norms are separate from biological normality. Sickle cell anemia, a physical ailment, possessing the ability to blur the lines of whether it is a disorder or not depending on geographical location proves once again the influence value judgements possess.
The notion that disease is free of value judgements is simply wrong. Numerous cases in medical history have demonstrated the alarming weight societal pressures places upon the idea of disorder. From drapetomania to homosexuality, value judgements have influenced people’s views of disease and diagnosis. As argued previously, value judgements are largely involved in evaluation of those suffering and medical personnel tend to take a hybrid approach to characterizing and diagnosing. Similar to Wakefield’s view, both value and scientific judgements make up the way we define disease and disorder, along with treatment methods. While Wachbroit makes some valid points about biological normality and its relationship with function, sickle cell anemia does present some function that progresses the organism towards it’s overall goal of survival, thus invalidating his argument. Additionally, the geographic factor’s relevance in how sickle cell anemia is viewed further validates that value judgements are present in the idea of disease. Society affects the treatment of known disease by circulating opinions and assumptions. The existence of value judgements in medicine more importantly allows for discovery and risk before scientific explanation can be provided, crucial for expanding the knowledge needed to alleviate patient suffering.