On Dis-ease
By Sam Vaknin
Author of "Malignant Self Love - Narcissism Revisited"

Threatened by yet another bird flu pandemic, we are well-advised to
study the very concept of disease.

We are all terminally ill. It is a matter of time before we all die.
Aging and death remain almost as mysterious as ever. We feel awed
and uncomfortable when we contemplate these twin afflictions.
Indeed, the very word denoting illness contains its own best
definition: dis-ease. A mental component of lack of well being must
exist SUBJECTIVELY. The person must FEEL bad, must experience
discomfiture for his condition to qualify as a disease. To this
extent, we are justified in classifying all diseases as "spiritual"
or "mental".

Is there any other way of distinguishing health from sickness - a
way that does NOT depend on the report that the patient provides
regarding his subjective experience?

Some diseases are manifest and others are latent or immanent.
Genetic diseases can exist - unmanifested - for generations. This
raises the philosophical problem or whether a potential disease IS a
disease? Are AIDS and Haemophilia carriers - sick? Should they be
treated, ethically speaking? They experience no dis-ease, they
report no symptoms, no signs are evident. On what moral grounds can
we commit them to treatment? On the grounds of the "greater benefit"
is the common response. Carriers threaten others and must be
isolated or otherwise neutered. The threat inherent in them must be
eradicated. This is a dangerous moral precedent. All kinds of people
threaten our well-being: unsettling ideologists, the mentally
handicapped, many politicians. Why should we single out our physical
well-being as worthy of a privileged moral status? Why is our mental
well being, for instance, of less import?

Moreover, the distinction between the psychic and the physical is
hotly disputed, philosophically. The psychophysical problem is as
intractable today as it ever was (if not more so). It is beyond
doubt that the physical affects the mental and the other way around.
This is what disciplines like psychiatry are all about. The ability
to control "autonomous" bodily functions (such as heartbeat) and
mental reactions to pathogens of the brain are proof of the
artificialness of this distinction.

It is a result of the reductionist view of nature as divisible and
summable. The sum of the parts, alas, is not always the whole and
there is no such thing as an infinite set of the rules of nature,
only an asymptotic approximation of it. The distinction between the
patient and the outside world is superfluous and wrong. The patient
AND his environment are ONE and the same. Disease is a perturbation
in the operation and management of the complex ecosystem known as
patient-world. Humans absorb their environment and feed it in equal
measures. This on-going interaction IS the patient. We cannot exist
without the intake of water, air, visual stimuli and food. Our
environment is defined by our actions and output, physical and
mental.

Thus, one must question the classical differentiation
between "internal" and "external". Some illnesses are
considered "endogenic" (=generated from the inside).
Natural, "internal", causes - a heart defect, a biochemical
imbalance, a genetic mutation, a metabolic process gone awry - cause
disease. Aging and deformities also belong in this category.

In contrast, problems of nurturance and environment - early
childhood abuse, for instance, or malnutrition - are "external" and
so are the "classical" pathogens (germs and viruses) and accidents.

But this, again, is a counter-productive approach. Exogenic and
Endogenic pathogenesis is inseparable. Mental states increase or
decrease the susceptibility to externally induced disease. Talk
therapy or abuse (external events) alter the biochemical balance of
the brain. The inside constantly interacts with the outside and is
so intertwined with it that all distinctions between them are
artificial and misleading. The best example is, of course,
medication: it is an external agent, it influences internal
processes and it has a very strong mental correlate (=its efficacy
is influenced by mental factors as in the placebo effect).

The very nature of dysfunction and sickness is highly culture-
dependent. Societal parameters dictate right and wrong in health
(especially mental health). It is all a matter of statistics.
Certain diseases are accepted in certain parts of the world as a
fact of life or even a sign of distinction (e.g., the paranoid
schizophrenic as chosen by the gods). If there is no dis-ease there
is no disease. That the physical or mental state of a person CAN be
different - does not imply that it MUST be different or even that it
is desirable that it should be different. In an over-populated
world, sterility might be the desirable thing - or even the
occasional epidemic. There is no such thing as ABSOLUTE dysfunction.
The body and the mind ALWAYS function. They adapt themselves to
their environment and if the latter changes - they change.
Personality disorders are the best possible responses to abuse.
Cancer may be the best possible response to carcinogens. Aging and
death are definitely the best possible response to over-population.
Perhaps the point of view of the single patient is incommensurate
with the point of view of his species - but this should not serve to
obscure the issues and derail rational debate.

As a result, it is logical to introduce the notion of "positive
aberration". Certain hyper- or hypo- functioning can yield positive
results and prove to be adaptive. The difference between positive
and negative aberrations can never be "objective". Nature is morally-
neutral and embodies no "values" or "preferences". It simply exists.
WE, humans, introduce our value systems, prejudices and priorities
into our activities, science included. It is better to be healthy,
we say, because we feel better when we are healthy. Circularity
aside - this is the only criterion that we can reasonably employ. If
the patient feels good - it is not a disease, even if we all think
it is. If the patient feels bad, ego-dystonic, unable to function -
it is a disease, even when we all think it isn't. Needless to say
that I am referring to that mythical creature, the fully informed
patient. If someone is sick and knows no better (has never been
healthy) - then his decision should be respected only after he is
given the chance to experience health.

All the attempts to introduce "objective" yardsticks of health are
plagued and philosophically contaminated by the insertion of values,
preferences and priorities into the formula - or by subjecting the
formula to them altogether. One such attempt is to define health
as "an increase in order or efficiency of processes" as contrasted
with illness which is "a decrease in order (=increase of entropy)
and in the efficiency of processes". While being factually
disputable, this dyad also suffers from a series of implicit value-
judgements. For instance, why should we prefer life over death?
Order to entropy? Efficiency to inefficiency?

Health and sickness are different states of affairs. Whether one is
preferable to the other is a matter of the specific culture and
society in which the question is posed. Health (and its lack) is
determined by employing three "filters" as it were:

1.. Is the body affected?
2.. Is the person affected? (dis-ease, the bridge
between "physical" and "mental illnesses)
3.. Is society affected?
In the case of mental health the third question is often formulated
as "is it normal" (=is it statistically the norm of this particular
society in this particular time)?

We must re-humanize disease. By imposing upon issues of health the
pretensions of the accurate sciences, we objectified the patient and
the healer alike and utterly neglected that which cannot be
quantified or measured - the human mind, the human spirit.


Sam Vaknin ( http://samvak.tripod.com ) is the author of Malignant
Self Love - Narcissism Revisited and After the Rain - How the West
Lost the East. He served as a columnist for Global Politician,
Central Europe Review, PopMatters, Bellaonline, and eBookWeb, a
United Press International (UPI) Senior Business Correspondent, and
the editor of mental health and Central East Europe categories in
The Open Directory and Suite101.

Until recently, he served as the Economic Advisor to the Government
of Macedonia.

Visit Sam's Web site at http://samvak.tripod.com