(I wrote one long post on Kukla and broke it into two. This is the second part.)
II. “What Counts as a Disease, and Why Does It Matter?”
(2022)
Eight years later, Kukla published “What Counts as a
Disease, and Why Does it Matter?” in The Journal of Philosophy of Disability (https://doi.org/10.5840/jpd20226613).
I downloaded a pre-print of this article at the time and have not tracked down a
copy with the proper pagination, so I will treat page 1 as the first page of
the article.
Kukla is a bit clearer about methodology this time. They
disavow the method of conceptual analysis, which is what Boorse and Wakefield
were doing. Instead, they contend that the role of the philosopher is “clarifying
the pragmatic and normative conditions under which ‘disease’ is a useful
concept that can be mobilized appropriately” (p. 6). This is more or less
exactly what I would expect a certain kind of pragmatist to say. It seems quite
close to the kind of thing Foucault tried to do with his ever-changing flotilla
of concepts for characterizing the underlying conditions for our discourses and
practices—historical a priori, dispositif, episteme,
problematization, etc. Of course, one does not have to accept any of this, but,
rather than argue for this way of construing philosophy’s task, I think it is
helpful here just to highlight the possibility of two radically different philosophical
approaches to the problem of the health concept.
Here is Kukla’s definition of disease:
“It is appropriate to classify a
condition as a disease if (1) it is strategically helpful, with respect to some
legitimate goal, to at least partially medicalize that condition or cluster,
and if (2) within the epistemology and metaphysics of medicine, the condition
or cluster can qualify as pathological” (p. 6)
Incidentally, Kukla states that they will use “disease” as a
catch-all term in this article and does not distinguish disease from disorder.
This is an explicitly hybrid definition. Consider condition
2 first: Kukla’s 2014 book chapter talked of medicalization but did not really consider
that there are limits—albeit dynamic, changing limits—on what can meaningfully
be medicalized from within medicine itself. Now, appealing to the “epistemology
and metaphysics of medicine” seems rather like punting, especially since it is
by no means evident what these consist of. Kukla acknowledges that medicine
actually consists of several distinct epistemological traditions. There are ways
to cash out the terms “epistemology” and “metaphysics” that make them a bit
more operationalizable, as Kukla discusses on pp. 9-10. For example, this seems
like a helpful clarification: “Medicalizing a condition involves taking it as
made up of the right sorts of entities and processes to be tracked and
understood using the epistemic tools of medicine. It is, for instance, to
understand it as a state or feature of an individual body rather than as a
relational feature of a social ecology” (p. 9). In my opinion, Kukla could
benefit here again from a genealogical or historical-epistemological approach
in the manner of Foucault or Canguilhem—or their followers. Such an approach
would seek to clarify the epistemological and metaphysical norms of medicine by
studying ruptures and changes in scientific and clinical practice over time.
As for condition 1, Kukla’s new move here, vis-à-vis the
2014 book chapter, is to acknowledge the vast and bewildering array of
strategic interests that medicalization can serve. Here are seven or eight goals
that medicalizing a condition might serve:
1.
Research interests, that is, promoting research
and investigation.
2.
Clinical interests, such as setting treatment
targets. (We can sometimes address a condition and reach treatment targets even
if we lack an understanding of etiology—as is the case in most forms of mental
illness.)
3.
Epidemiological interests, such as interests in
studying the spread or transmission of a phenomenon.
4.
Institutional interests, such as what an
insurance plan should cover.
5.
Economic interests.
6.
Political interests, such as what role the state
should play with respect to the condition.
7.
Interests in self-understanding of roles and
responsibilities related to the condition. (pp. 4-5). This last consideration
bears on questions about individual and collective identity, but also stigmatization
of certain identities.
Here are just some of the tricky examples Kukla brings up:
the medicalization of obesity; the medicalization of prodromal states, such as
pre-hypertension (from a mental health perspective, I would add the
psychiatrization of clinical high-risk for psychosis as a distinct nosological
category); alcoholism/alcohol use disorder; and gender dysphoria. These are all
areas in which there are many, many different strategic interests involved.
If you feel overwhelmed here, good. You should be, says
Kukla, more or less:
“[T]here is literally no one who
could possibly have the expertise to be in an authoritative position from which
to balance and settle all these various strategic questions…. The best we can
hope for is consensus when we need it for the purpose of large-scale social
decision-making, and even then consensus may be elusive. This is not because
there is some truth of the matter we failed to uncover, but because of the
pluralist, fundamentally pragmatist nature of the concept of disease.” (24)
In my first post on Boorse, I talked about some of his
underlying motivations for elaborating a value-free concept of health—avoiding the
colonization of our moral universe by the concept of health, drawing a line
between health and social deviancy, and defending a concept of mental health
and illness against anti-psychiatry. What I think Kukla is trying to do here is
say: Yes, we can try to do these things, and we may want to do other things
too with our concepts of health and disease. We do a lot more with these
concepts than I even acknowledged in 2014. However, there is no magic bullet
for any of this. We have to plod through the terribly complex nexus of
interests and issues that are at stake for us in the dynamic process of
medicalization.
One can alternatively find this position defeatist or
honest. I incline toward the latter. I think anyone who interacts with the
mental health system in any capacity, but perhaps especially clinicians, would
do well to consider it. But I also think there is an important caveat needed
here. We don’t need to be black-and-white about disease attributions. We can
entertain multiple perspectives at the same time; perhaps we must—I think any
good clinician must. In other words, the choice is not that we must either
consider a condition mental illness or not. There are moments when I think it
makes sense both strategically and metaphysically to look at the same
phenomenon at the same time as both an illness and as many other things.
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