77486927 pharmacracy-medicine-and-politics-in-america-2001-by-thomas-stephen-szasz


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77486927 pharmacracy-medicine-and-politics-in-america-2001-by-thomas-stephen-szasz

  2. 2. Pharmacracy
  3. 3. PharmacracyMEDICINE AND POLITICS IN AMERICA Thomas Szasz
  4. 4. Library of Congress Cataloging-in-Publication DataSzasz, Thomas Stephen, 1920– Pharmacracy : medicine and politics in America / Thomas Szasz. p. cm. Includes bibliographical references and index. ISBN 0–275–97196–1 (alk. paper) 1. Social medicine—United States—Miscellanea. 2. Medical care—Political aspects—United States. 3. Medical ethics—United States. I. Title. RA418.3.U6S936 2001 362.1′0973—dc21 00–064948British Library Cataloguing in Publication Data is available.Copyright © 2001 by Thomas SzaszAll rights reserved. No portion of this book may bereproduced, by any process or technique, without theexpress written consent of the publisher.Library of Congress Catalog Card Number: 00–064948ISBN: 0–275–97196–1First published in 2001Praeger Publishers, 88 Post Road West, Westport, CT 06881An imprint of Greenwood Publishing Group, Inc.www.praeger.comPrinted in the United States of AmericaThe paper used in this book complies with thePermanent Paper Standard issued by the NationalInformation Standards Organization (Z39.48–1984).10 9 8 7 6 5 4 3 2 1
  5. 5. For George,my teacher, my friend, my brother, with gratitude and love
  6. 6. The species of oppression by which democratic nations are menaced is un-like anything that ever before existed in the world; our contemporaries willfind no prototype of it in their memories. I seek in vain for an expression thatwill accurately convey the whole of the idea I have formed of it; the old wordsdespotism and tyranny are inappropriate: the thing itself is new. . . . The firstthing that strikes the observer is an innumerable multitude of men, all equaland alike, incessantly endeavoring to procure their petty and paltry pleasureswith which they glut their lives. . . . Above this race of men stands an immenseand tutelary power, which takes upon itself alone to secure their gratificationsand to watch over their fate. The power is absolute, minute, regular, provident,and mild. It would be like the authority of a parent if, like that authority, its ob-ject was to prepare men for manhood; but it seeks, on the contrary, to keepthem in perpetual childhood. . . . For their happiness such a government will-ingly labors . . . provides for their security . . . facilitates their pleasures, man-ages their principal concerns . . . what remains, but to spare them all the care ofthinking and all the trouble of living? Alexis de Tocqueville (1805–1859) A. de Tocqueville, Democracy in America, vol. 2, p. 336.
  7. 7. CONTENTSPreface xiAcknowledgments xviiAbbreviations xixIntroduction: What Counts as a Disease? xxi1. Medicine: From Gnostic Healing to Empirical Science 12. Scientific Medicine: Disease 93. Clinical Medicine: Diagnosis 274. Certifying Medicine: Disability 575. Psychiatric Medicine: Disorder 776. Philosophical Medicine: Critique or Ratification? 1117. Political Medicine: The Therapeutic State 127Epilogue 161
  8. 8. ContentsNotes 167Selected Bibliography 191Index 203 x
  9. 9. PREFACE Neither must we suppose that any one of the citizens belongs to himself, for they all belong to the state, and are each of them a part of the state, and the care of each part is inseparable from the care of the whole. Aristotle1Physicians, politicians, public policy experts, people in nearly every walk of lifespend a great deal of time and energy debating what is and what is not a diseaseor a treatment. Although these questions appear to be about phenomena orfacts, they are, more often than not, about policies or strategies. Formerly, weapproved and disapproved, permitted and prohibited various behaviors be-cause they were virtuous or wicked, legal or illegal. Now, we do so because theyare deemed healthy or sick, therapeutic or pathogenic. Hence the seeminglyunappeasable thirst to medicalize, pathologize, and therapeutize all manner ofbehaviors manifesting as personal or social problems. The upshot is that we tend to substitute ostensibly medical criteria for ex-plicitly moral criteria for judging character and personal conduct and usepseudomedical arguments to justify the expansion and exercise of state power.How has this transformation come about, and why do we embrace it as if itwere medical, moral, and political progress? In the ancient world, as the epigraph by Aristotle illustrates, the individualwas not a person unless he was a part of the polis; the personal and the politicalwere intimately interrelated. Today, under American constitutional principles,
  10. 10. Prefacethe personal and the political are distinct spheres, the desires of individuals areoften in conflict with the needs of the group or the nation or the state, and thisconflict is often obscured by invalidating the individual’s desires as the “symp-toms of illness.” If the welfare of the individual and the welfare of the collective are consid-ered to coincide, then the ill health or ill conduct of each endangers that of theother. In the absence of clear separation between the personal and the political,the private and the public, there can be no separation between private healthand public health. The personal then becomes political and politics becomes,intrinsically, “therapeutic.” (Henceforth, I shall avoid placing words like “med-ical” and “therapy” between scare quotes to indicate their metaphorical orironic use and let the context clarify my meaning.) The Reformation and the Enlightenment created a sharp division betweenthe personal and the political, perhaps nowhere more so than in the newlyfounded American republic. Yet, the more public policy recognizes and re-spects this division, the more politically divisive become the conflicts betweenthe wants of the person and the needs of the polity. “A man may not always eatand drink what is good for him,” said George Santayana (1863–1952), thegreat American philosopher, “but it is better for him and less ignominious todie of the gout freely than to have a censor officially appointed over his diet,who after all could not render him immortal.”2 Gilbert K. Chesterton(1874–1936), a conservative Catholic journalist and social critic, took forgranted that “the free man owns himself. He can damage himself with eithereating or drinking; he can ruin himself with gambling. If he does he is certainlya damn fool, and he might possibly be a damned soul; but if he may not, he isnot a free man any more than a dog.”3 Today, hardly any right-thinking person holds these beliefs. Collectivistsand totalitarians dream of the brotherhood of man—protecting one anotherand the fatherland from enemies within and without. Individualists and liber-tarians long to be left alone by the state—although, in their hearts, too, thereoften lurks the temptation to enlist its protection when certain dangersthreaten. How are we to reconcile these seemingly irreconcilable aspirations?The modern mind has seized on the ideas of disease and treatment as offeringcommon ground. Disease often threatens, and treatment often benefits, indi-viduals and groups alike. Saving people from disease, like saving their souls, is agood that no one (in his right mind) could have reason to reject. In the words offormer Surgeon General C. Everett Koop: “The government has a perfect rightto influence behavior to the best of its ability if it is for the welfare of the indi-vidual and the community as a whole.”4 That is a dangerous opinion, the moreso because ever fewer people realize that it is dangerous. xii
  11. 11. Preface With victory in World War II and the Cold War, the United States bestridesthe world like no power has since the Roman Empire. Because politics, by defi-nition, entails the exercise of power, and because the most elementary exerciseof power is waging war, American hegemony presents a problem: there is no lit-eral enemy to subdue. Yet, just as the metabolism of the body anatomic re-quires nutrients, so the metabolism of the body politic requires enemies or, atleast, scapegoats. In a tacit compact, rulers and ruled unite to create enemies byalienating parts of their own nation or aspects of human nature itself: “They”are “diseases,” caused by microbes, genes, chemicals out of balance, economicexploitation, or abusive parents—and “they” are attacking “us.” They arewicked. We are virtuous. The experts tell us that we eat too much, drink too much, smoke too much,gamble too much, take too many drugs; that we behave irresponsibly with re-spect to sex, marriage, procreation, exercise, and health care; that we committoo many murders and suicides, too many assaults, thefts, and rapes; and thatall these things are not really our own doings but the manifestations of mala-dies. In the past, politicians seized power by declaring national emergencies.Now they do so by declaring public health emergencies. Alcoholism, obesity,suicide, and violence, they say, are killing Americans. Individuals are not re-sponsible for eating or drinking too much, for killing themselves or others. Therejection of personal responsibility for one behavior after another—each delib-erate act transformed into a “no-fault disease”—drives the politics of therapy.The government declares war on drugs, cancer, heart disease, obesity, mentalillness, poverty, racism, sexism, suicide, and violence. However, drug addictsrefuse to abstain from drugs, the obese overeat, the mentally sick reject beingtreated as patients, and the poor refuse to adopt the habits of the rich. Copingwith these and other “health emergencies” requires enlarging the scope and co-ercive powers of medicine as an arm of the state. In the long run, neither exaggerating the claims or rights of the individualnor exaggerating the obligations and beneficence of the state serves the cause ofexpanding liberty under law. We live in societies more complex than ever andare dependent on one another more, and more anonymously, than ever. Noperson can be free without shouldering his responsibilities, and no society canendure without penalizing irresponsible behavior. Liberty is undermined bythe irresponsible individual and is destroyed by tyrannical government. Biologically, we are animals and, as such, we are predators or prey or both.To avoid becoming prey, we live in groups—families, tribes, states—whoserules regulate our conduct. The concept of the state as guardian—parent, sov-ereign, or night watchman, protecting members of the group from enemieswithout and within—is basic to Western political philosophy. However, xiii
  12. 12. Prefacebecause of man’s predatory nature—homo homini lupus (“man is a wolf toman”), as the Romans put it—this idea is intrinsically self-contradictory. Whatis there to prevent the guardians from yielding to the temptation to prey on thepeople they are supposed to protect? We may think of political philosophy as be-ginning when the Roman poet and satirist Juvenal (c. 60–140) posed the classicquestion: “Quis custodiet ipsos custodes?” “Who shall guard the guardians?” Throughout history, most people have preferred to ignore this challenge.For a very long time, people sought comfort in guardians whose goodness wasguaranteed by God, which let them place their trust in rulers whom they re-garded as deputies of a deity, exemplified by the divine rule of popes and Chris-tian sovereigns. The founders of the United States formed a different plan forprotecting the American people from their own protectors. They and theircompatriots regarded themselves as competent and responsible adults. Thus,the American Revolution was, in effect, a revolt of the grown child against hisfather intent on keeping him in tutelage: it was a demand for theself-government and self-responsibility that befits a dignified person, not formore largesse for a ward victimized by his dependence. This is what gave theFounders the strength to resist the temptation to replace one paternal govern-ment with another. Instead, they sought to create a nonpaternal governmentand they proceeded to construct one. Like a fearful child dreaming of a fairy godmother, the puerile mind dreamsof the trustworthy ruler. Liberated from that delusion, the mature mind recog-nizes not only that power corrupts but also that those who seek power tend tobe corrupt, and hence distrusts all rulers. Rulers ought to be watched with sus-picion, not worshiped. Thus, the Founders endeavored to avoid the danger ofdespotic government by limiting its scope—delegating powers to states com-posing a confederation of independent political units—and by creating a gov-ernment of divided powers—one branch checking and balancing the powersof the others. Although never fully realized, that, at least in theory, was the vi-sion that characterized American polity from 1787 until 1861. Today, that vision is a thing of a past existentially more distant from us thanancient Rome was from the Founders. The Founders understood that thegreatest danger to man is other men, especially when they are out to protecthim from himself. Forgetting that maxim, modern man thirsted for powerfulrulers to protect him and, in the twentieth century, he found just what he waslooking for: These “strong men” managed to kill more people, including theirown, than have all past rulers combined. What do we now fear the most? The answer, issuing from the most respectedsources, is loud and clear: responsibility for our own behavior. The dominantethic rests on two premises: (1) We are responsible only for our good deeds; (2)our bad deeds are diseases or the products of diseases for which we are not re- xiv
  13. 13. Prefacesponsible. This doctrine tells us that we can no more combat alcoholism andpanic disorder with will power than we can amebiasis and parkinsonism. Onlytreatment can remedy such problems. Our duty is to pay more taxes, to enablegovernment scientists to discover cures for these diseases, and to recognize thatwe are ill and place ourselves in the care of health care agents of the state, to be-gin the lifelong process of recovery. “I would hopefully be a good role model.I’m in recovery,” declares Cindy McCain, wife of Senator and former presi-dential hopeful John McCain (R-Az).5 Mrs. McCain had used controlled sub-stances that she had stolen while she worked as a member of a “charity she hadset up to send medical relief to the Third World.”6 The one thing we must notdo is assume that how we live is our own business and responsibility. Thispackage is now usually sold under the label of promoting “patient autonomy,”a term that, as I showed elsewhere, is now an integral part of the semantics ofsocial control through medicine.7 While awaiting medical research to solve the riddle of the biological roots ofproblematic behaviors conceptualized as diseases and provide a cure for them,people must, however, cope with the personal and social problems they face.Cope with them they do, as predators are predisposed to, by waging literal warson people allegedly suffering from the metaphorical plagues of drugs, racism,violence, and human nature itself. The delusionary goal of an America free ofdrugs, free of disease, free of strife, suicide, and violence—of death itself—jus-tifies these wars waged by a tacit agreement between a populace eager to rejectresponsibility for self-discipline and its political representatives eagerly pan-dering to that longing. How? By declaring that human problems are diseasesthat medicine will soon conquer, just as it has conquered polio and smallpox.Thus, the boundaries of medicine expand until they encompass all human as-pirations and actions. Comforted by the delusionary concept of “no-fault disease,” the illness in-flation set in motion by the medicalization of (mis)behavior accelerates and, inturn, intensifies the tendency to reject responsibility for (mis)behavior. We areloath to use the criminal laws to control genuine criminals, that is, people whodeprive others of life, liberty, or property. We are unwilling to control our chil-dren, who, in turn, are unwilling or unable to control their own behavior.Judges sentence criminals to “treatment programs,” and school authori-ties—aided and abetted by physicians, psychologists, and parents—manageunruly children with “prescription drugs” and lectures about our nationalstruggle for a “drug-free America.” Truly, we have become Santayana’s “fanat-ics” who, after losing sight of their goal, redouble their effort. Actually, we Americans are now healthier than we have ever been and livelonger than we have ever lived. Why, then, do we perceive our existential prob-lems in medical terms and seek their solution in a tyranny exercised by thera- xv
  14. 14. Prefacepeutic tribunes? Why should a healthy people dread disease so much?Although the fear may seem paradoxical, there is logic in it. In 1776, Americans enjoyed more political freedom than they ever did asEnglishmen or colonists. That is precisely why they valued liberty and werezealous in guarding it against tyrannical rulers. It is the free and the rich, notthe enslaved and the poor, who worry about losing their liberty and theirmoney and seek to protect themselves from those dangers. It is the healthy, notthe sick, who worry about losing their health and seek to protect themselvesfrom that danger. We are medically richer than people have ever been. We havegained more control over real diseases than we would have dreamed possible ahundred years ago. It is precisely these advances that have encouraged extend-ing the idiom, imagery, and technology of medicine to other areas of humanconcern, transforming all sorts of human problems into “diseases,” and therule of law into the rule of medicine, in a word, “pharmacracy.”8 A brief remark about this term is in order here. The Greek termpharmakon—a so-called primal word, possessing antithetical mean-ings—meant both drug and poison. The term pharmakos referred to a ceremo-nially sacrificed scapegoat, whose death purified and thus cured/saved thecommunity. In 1976, in Ceremonial Chemistry, I wrote: “Inasmuch as we havewords to describe medicine as a healing art, but have none to describe it as amethod of social control or political rule, we must first give it a name. I proposethat we call it pharmacracy, from the Greek roots pharmakon, for ‘medicine’ or‘drug,’ and kratein, for ‘to rule’ or ‘to control.’ . . . As theocracy is rule by God orpriests, and democracy is rule by the people or the majority, so pharmacracy isrule by medicine or physicians.”9 In a theocracy, people perceive all manner ofhuman problems as religious in nature, susceptible to religious remedies; simi-larly, in a pharmacracy people perceive all manner of human problems as medi-cal in nature, susceptible to medical remedies. Specifically, I shall use the term“pharmacratic controls” to refer to social sanctions exercised by bureaucratichealth-care regulations, enforced by health-care personnel, such as alcoholtreatment and other addiction programs, school psychology, suicide preven-tion, and the mandatory reporting of personal (mis)behavior as part of the du-ties of physicians and other health-care personnel. My aim in this book is to show that the effort to medicalize life is not onlycognitively ill-conceived, it is also politically perilous. Conflict is intrinsic tohuman existence. Regulating disagreements as if they were diseases is a recipefor forfeiting liberty in pursuit of an illusory therapeutic paradise on earth. xvi
  15. 15. ACKNOWLEDGMENTSI am most grateful to my brother George, daughter Margot Peters, son-in-lawSteve Peters, and my friends Alice Michtom, Robert Schneebeli, and RogerYanow for their extensive corrections, comments, criticisms, and suggestions.This acknowledgment does not do justice to their contribution, let alone theirpatient labors. I also cannot do justice to acknowledging the generous help ofPeter Uva, librarian at the State University of New York Upstate Medical Uni-versity, with this book and with many others in the past. Finally, I wish to thankthe Greenwood Publishing Group for producing books by an authorwho—paraphrasing Samuel Butler—never writes on any subject unless he be-lieves the opinion of those who have the ear of the public to be mistaken, andthis involves, as a necessary consequence, that every book he writes runs coun-ter to the men who are in possession of the field.1
  16. 16. ABBREVIATIONSADHD attention deficit hyperactivity disorderAIDS acquired immune deficiency syndromeAMA American Medical AssociationAPA American Psychiatric AssociationAWDA Americans with Disabilities ActDEA drug enforcement agencyDOT directly observed therapyDRG diagnosis-related groupDSM Diagnostic and Statistical Manual of Mental Disorders (of the APA)HMO health maintenance organizationICD International Classification of DiseasesNHS National Health Service (UK)NIDA National Institute of Drug AbuseNIH National Institutes of HealthNIMH National Institute of Mental HealthPTSD posttraumatic stress disorderS.S.R.I. selective serotonin reuptake inhibitorSUNY State University of New York
  17. 17. AbbreviationsVIP very important personVUP very unimportant personWHO World Health Organization xx
  18. 18. INTRODUCTION What Counts as a Disease? Vicissitudes of fashion will enforce the use of new, or extend the significa- tion of known terms. The tropes of poetry will make hourly encroach- ments, and the metaphorical will become the current sense . . . illiterate writers will at one time or other, by publick infatuation, rise in renown, who, not knowing the original import of words, will use them with collo- quial licentiousness, confound distinction, and forget propriety. Samuel Johnson (1775)1What is a disease? What is not a disease? Although most people think theyknow the answer, few have a clear idea of what is and what is not a disease. Thisis hardly surprising. The word “disease”—and its synonyms, “ailment,” “ill-ness,” “malady,” “sickness”—is used in diverse ways and has a multiplicity ofmeanings. In the end, people decide what is and what is not a disease by whatbest suits their needs or on the basis of the hoary rule, “I know one when I seeone.” To bring order to our disorderly use of language, we distinguish between theliteral and the metaphorical uses of terms. The root meaning of the term“honey,” for example, names the substance secreted by bees. When a man callshis wife “honey,” he is speaking metaphorically. The distinction between literaland metaphorical meaning is, of course, a matter of convention: it requiresagreement about the root meaning of the particular term. The point is that un-less we assign a discrete, limited, identifiable meaning to a term, we cannot dis-
  19. 19. Introductiontinguish between its literal and metaphorical uses and cannot use the term withprecision. Our enquiry must therefore begin with a clarification of the root meaningof the term “disease.” To what object or phenomenon does the term refer?Framed about particulars, there is likely to be general agreement about the an-swer: typhoid fever is a disease, spring fever is not. However, framed abstractly,there is likely to be disagreement. Why? Because we lack unanimity about whywe regard typhoid fever, but not spring fever, as a disease. That is why we fruitlesslydebate whether drug addiction, clinical depression, pathological gambling, so-cial anxiety, and so forth are or are not diseases. Unless we agree on the rootmeaning of the term “disease,” we cannot know what counts as a literal diseaseand what counts as a metaphorical disease, that is, not a true disease. Similarconsiderations account for the futility of debating whether abortion, euthana-sia, surgical remedies for transsexualism, and many other procedures per-formed by physicians are or are not treatments. Knowing the difference between the literal and metaphorical uses andmeanings of words is not a special skill. It is a matter of knowing how to use lan-guage properly. In certain areas of life—religion, in particular—individualswillingly suspend their knowledge of this distinction, a sacred text becoming“literally” the word of God. I regard this as evidence of the near-universality ofthe understanding of the distinction between the literal and the metaphorical.Clearly, even people unfamiliar with the terms “literal” and “metaphorical”recognize the difference. Everyday speech, humor, poetry, and technical jargonall depend on enriching literal meanings with figures of speech. Some virusesattack the immune system, others attack computer programs. No one mistakescomputer viruses for biological agents. This book is, in part, an argument about what should count as a disease.How that argument is resolved affects so many aspects of everyday life that itmay be no exaggeration to say it is the single most important issue in contem-porary American life. “What is the good of words if they aren’t importantenough to quarrel over?” asked G. K. Chesterton. “Why do we choose oneword more than another if there isn’t any difference between them? If youcalled a woman a chimpanzee instead of an angel, wouldn’t there be a quarrelabout words? If you are not going to argue about words, what are you going toargue about?”2 If we fail to settle the argument about what should count as adisease, or settle it on the basis of capricious, politically grounded criteria, weincapacitate ourselves from thinking clearly about what should count as healthcare or treatment, who should pay for it, and the many other health policy is-sues we now argue about. Failure to distinguish between the literal and figurative uses of words may bedue to ignorance or, when powerful human interests are at stake, may be a part xxii
  20. 20. Introductionof a deliberate strategy and an institutionally mandated policy. Our use of theverb “to medicalize” is instructive in this connection: the locution depends onand betrays a tacit understanding of the limited scope of medicine, and hence of thecore meaning of disease. We speak about medicalizing suicide or violence, tacitlyacknowledging that we are enlarging the scope of medicine, and we recognizethe absurdity of speaking about medicalizing malaria or melanoma, tacitly ac-knowledging the proper sphere of medicine. Similar considerations hold forthe terms “politicize” and “theologize.” (Webster’s Third New InternationalDictionary and the Oxford English Dictionary both have entries for “politicize”and “theologize,” but neither has an entry for “medicalize.”) When religion reigned and church and government were united in a theo-logical state, people perceived countless human problems as the products of di-vine or satanic intervention, and sought to remedy them with appropriatereligious interventions, such as prayer and exorcism. When science reigns andmedicine and the government are united in a therapeutic state, people perceivecountless human problems as the products of diseases, and seek to remedythem with medical interventions, such as drugs and “therapy.” I should notehere, perhaps, that I coined the term “therapeutic state” in 1963 with deliber-ate irony, as a critical and dishonorific sobriquet, to denote the political unionof medicine and the state, physicians playing the same sorts of ambiguous,double roles that priests played when church and state were united. The ambi-guity, coercion, and paternalism intrinsic to such a role of the physician—sometimes helping the patient, sometimes harming him—is incompatiblewith individual dignity, liberty, responsibility, and the rule of law. I regard thetherapeutic state as a type of totalitarian state, persecutions in the name ofhealth by doctors replacing persecutions in the name of God by priests.3 (Somewriters now use the term approvingly, denoting a medicalized variant of thewelfare state or an ideal, scientifically enlightened polity.) As a science, medicine rests on and makes use of the same methods and prin-ciples as the physical sciences. One of these principles is that the observer is aperson, and the object he observes is not. Chemists and physicists observe, forexample, the characteristics of various elements and classify them as helium,lithium, uranium, and so forth. The classification serves the interests of theclassifiers. The objects classified have no interests. To understand the many conceptual, economic, and political problems thatbeset contemporary medical practice, that is, medicine as health care, we mustdistinguish between scientific medicine, whose objects of study are diseasesthat affect human beings, and clinical medicine, whose objects of study arepersons, usually called “patients.” Making this distinction does not imply thatone is intellectually, morally, or practically better or more important than theother. Each enterprise has its own agenda and vocabulary. xxiii
  21. 21. Introduction• The aim of scientific medicine, an enterprise barely 150 years old, is to increase our understanding of the causes and cures of conditions scientifically defined as dis- eases. The aim of clinical medicine, which may be said to be as old as civilization, is to help persons regarded as sick recover their health.• The practitioner of medical science seeks to understand disease. The practitioner of clinical medicine seeks to relieve dis-ease.• Scientific medical knowledge is indifferent to individual or collective human well-being; it may be equally useful for biological warfare and the relief of hu- man suffering. In contrast, the raison d’être of clinical medicine is the welfare of the patient. Diverse concepts of disease—ranging from the objective to the subjective,from the literal to the metaphorical, from uremia to insomnia—are now com-pelled to coexist, in scientific, clinical, and political medicine. Compelled bywhom? By authorities in science, medicine, the media, politics, and the law, ina word, by the Zeitgeist. The suggestion that, say, AIDS and ADHD (acquiredimmune deficiency syndrome and attention deficit hyperactivity disorder) areradically different kinds of diseases—or, more precisely, that the latter is not adisease at all—is politically so incorrect that it is dismissed out of hand. Without a solid consensus on what is a literal disease, how would we recog-nize a metaphorical disease if we met one? xxiv
  22. 22. 1 MEDICINE From Gnostic Healing to Empirical Science For he [God] makes sore, and bindeth up: he woundeth, and his hands make whole. Job 5:17–18 Disease: A condition of the body, or of some part or organ of the body, in which its functions are disturbed or deranged; a morbid physical condi- tion. Oxford English DictionaryIn the ancient world, disease was a gnostic concept, concerned with “spiritualtruth,” not with empirical evidence. In Biblical, Greek, and Roman accounts,disease is a holistic-theistic concept that precludes distinguishing between lit-eral and metaphorical illnesses, between diseases of the body and diseases of themind. There is no Latin word for our scientific concept of disease. When theRomans spoke of disease, they used the word “morbus”—the root of the Eng-lish words “morbid” and “morbidity”—which also means disaster, fault, andvice; or the word “malum”—the root of such English words as “malefactor” and“malevolent”—which also means evil, harm, hardship, and punishment.1 TheKing James Version of the Scriptures uses the terms “murrain,” “plague,” and“pestilence,” instead of the term “disease.” The Revised Standard Version uses“plague” throughout. Accordingly, the act of healing entailed intermingling
  23. 23. Pharmacracynatural and supernatural means of influence, medical and religious methods oftreating the body and the mind. In the biblical view, as the story of Job illustrates, the cause of both diseaseand cure is God. Vexed by Job’s piety, Satan seeks God’s permission to temptJob to curse the Lord and thus demonstrate his moral imperfection. “And theLord said unto Satan, Behold, he is in thine hand. . . . So went Satan forth fromthe presence of the Lord, and smote Job with sore boils from the sole of his footunto his crown.”2 The parable demonstrates God’s medical omnipotence: “Be-hold, happy is the man whom God correcteth. . . . For he makes sore, andbindeth up: he woundeth, and his hands make whole.”3 Ancient gnostic concepts of disease and treatment are incommensurablewith their modern, materialist counterparts. In the gnostic view, both diseaseand treatment are the results of divine intervention—the former, punishmentfor sinning, the latter, reward for repentance. In the materialist view, both dis-ease and treatment are “natural” processes—the former having many possiblecauses, often microbes, the latter typically cured by chemicals, often availableby prescription only. From the materialist point of view, the phenomenon of disease is, of course,older than the human race and affects all life forms. Sir Marc Armand Ruffer(1859–1917), one of the founders of paleopathology—the science of the dis-eases “that can be demonstrated in human and animal remains of ancienttimes”—observed that “wild primates suffer from many disorders, includingarthritis, malaria, hernia, parasitic worms, and impacted teeth. Our ancestorspresumably experienced disorders and diseases similar to those found amongmodern primates.”4 Hippocratic medicine is a blend of gnostic and materialist elements. Insteadof viewing disease as a discrete lesion or process, the Hippocratics saw it as a dis-turbance affecting the whole person through an imbalance among the four hu-mors, blood, phlegm, black bile, and yellow bile. These humors, together withthe four associated qualities—hot, cold, moist, and dry—form the microcosmof the human body and reflect the four elements—earth, air, fire, and wa-ter—that make up the macrocosm or universe. “Health is the result of the har-monious balance or blending of the four humors.”5 I recapitulate these familiar facts to underscore that whereas the humoralmodel of disease is holistic, etiological, and spiritual, the pathological model ofit is localized, phenomenological, and material. I do this to show that, contraryto the claims of its supporters, the modern biopsychosocial image of ill-ness—emphasizing explanation over phenomenon and treatment over under-standing—represents a regression to the prescientific conception of illness, nota progression beyond the pathological conception of it. 2
  24. 24. MedicineTHE IDEA OF ILLNESS: A BRIEF HISTORY In the ancient world, people feared and held the dead body in superstitiousawe. This sentiment, deeply seated in the human mind, continues to linger inthe popular imagination and forms one of the permanent sources of religion.As long as this sentiment was strong and socially sanctioned as rational, it pre-cluded examining a dead body to study its structure and function. Doing sowould have violated an unarticulated taboo, rooted in the Greeks’ fear of andaversion to caducity, manifested by their idealization of the youthful, hale,whole, and healthy. This is why Hippocrates had not the faintest idea about whatis inside the body, a subject into which he neither wished nor dared to inquire. Although Aristotle studied animals and is sometimes said to be the founderof comparative anatomy, he believed that the heart is the seat of the intellect,because it beats. The anatomical fantasies of the ancients were systematized byGalen (2nd century A.D.), the most famous physician of antiquity. The Jewish,Christian, and Islamic religions catered to man’s instinctive dread of the deadbody by prohibiting the dissection of the corpse. For the next thousand years,physicians studied books, not bodies. The answers to the riddles of disease layin the writings of Aristotle and Galen, not in observation and experiment. Thissituation lasted roughly until the Enlightenment. How could the premodern physician, ignorant of the makeup of the body,treat diseases? The story of prescientific healing has been told many times anddoes not belong here. Like the quack today, the ancient healer, too, was con-vinced that he knew what he was doing and his customers were satisfied withhis services. One of the most absurd conceits of modernity is the belief that oursick forebears were bereft of medical help. For minor maladies—such as coldsor small wounds, viewed as a natural part of everyday life—they had a vast ar-ray of herbal medicines. For major maladies—such as the “plague,” viewed asdue to supernatural sources—they had priests, prayer, and scapegoats to sacri-fice to the gods. Indeed, if diseases are perceived as supernatural in character, itfollows that their causes and cures are beyond the ken of secular healers, whowould therefore have been prepared to refrain from hard-nosed inquiry intotheir nature by genuine (not necessarily priest-imposed) awe of diseases. Deluged by incessant advertising and propaganda about medical treat-ments, people forget that Christianity is not only a faith of redemption but alsoa faith of healing, of both body and soul. Unlike Abraham, Jesus is not only aprophet, he is also a healer, the Divine Physician, the Savior (der Heiland, inGerman). For centuries, Christians regarded sickness as punishment for sin,curable by means of prayer, repentance, sacrifice, and the aspersion of holy wa-ter by a priest, the representative of an all-forgiving deity. 3
  25. 25. Pharmacracy To be plague-stricken was to be smitten by God. This put people in a bind:They believed in the theological explanation of the “plague,” at least in part,because they could not get at the natural, physical cause of it, and then they re-frained from trying to get at the root of the evil because they thought the evilwas brought on by the hand of God. Furthermore, everyday life was repletewith proof of the efficacy of miraculous cures for illnesses of all kinds. Shrineswith powers of healing dotted the Christian landscape. More than 5 millionpilgrims a year still visit Lourdes, and, to this day, the Vatican’s official proce-dure for sanctification depends on medical proof of the would-be saint’s havingperformed at least two miraculous cures. We have specific chemicals for specific diseases. Christians had (and stillhave) specific saints for curing specific ailments. The martyred twins, Cosmasand Damian (c. 303) were the patron saints of medicine in general. St. Vitushad powers to cure chorea (St. Vitus’ dance), St. Anthony, to cure erysipelas(Anthony’s fire), and St. Rochus, to cure the plague. When Christian mon-archs were revered as quasi-divine, their touch was considered curative, espe-cially for scrofula. Revealingly, until c. 1700, the French king would say: “Le roite touche, Dieu te guérit” (“The king touches you, God cures you”). In the eigh-teenth century, the magic mantra was modified: The king would say:“Le roi tetouche, Dieu te guérisse” (“The king touches you, may God cure you”). The laying on of hands was transformed into a pseudoscientific “system” byFranz Anton Mesmer (1733–1815): He laid on his hands, and magnetismcured. Before long, the healing power of magnetism was replaced by the heal-ing power of “hypnosis.” Mesmer’s name has become a part of our languageand his work forms both a spiritual and materialist bridge between what I con-sider magical, ceremonial, or personal healing on the one hand, and material,scientific, and impersonal treatment on the other.6 In short, prior to the nineteenth century, neither physicians nor patientshad a precise idea about what was and what was not a disease. Disease was sim-ply a discomfort and a danger, often leading to death, to be avoided and re-lieved as best one could. For centuries, self-medication with herbalremedies—principally opium, alcohol, and tobacco—constituted the suffer-ing person’s main protection against illness and pain. As the taboo against treat-ing the body slowly lifted, there arose diverse corps of professional healers:barber surgeons performing operations; herbalists prescribing medicines de-rived from plants; and doctors of medicine relying mainly on purging the bodyof presumed toxic substances believed to be the causes of disease. Among secular healers, barber surgeons were perhaps the most scientific,because their procedures were empirical, and physicians the least scientific, be-cause their procedures were speculative. In fact, the mentality of theprescientific physician was essentially magical-religious, but he applied his 4
  26. 26. Medicinecraft to the sufferer’s vile body, rather than to his wicked soul. This accountsfor the jealous rivalry between priest and physician, and the absence of such ri-valry between priest and barber surgeon. The persistence of the mysti-cal-religious, Galenic-humoral image of illness right up to the nineteenthcentury also accounts for the long popularity of premodern medicine’s pana-cea, purging—epitomized by bloodletting. Those who believed in such ideasand interventions worshiped them as rational cure-alls; those who did not, dis-missed them as foolish quackeries. The Core Concept of Disease: The Body as a Machine The waning influence of religion and the waxing prestige of science wereslow and gradual processes. In the sixteenth century, the Church began to au-thorize the dissection of executed felons. Although physicians participated inthis enterprise, the true fathers of anatomy were the great Renaissance artists,especially Michelangelo and Leonardo da Vinci. The birth of anatomy, as the basis of scientific medicine, is usually attrib-uted to Andreas Witing, a physician from Wesel on the Rhine, better known byhis Latin name, Vesalius. In 1543, Vesalius, a professor of anatomy at the Uni-versity of Padua, published De humani corporis fabrica [The Makeup of the Hu-man Body]: for the first time in history, people were able to “see, in beautifuland accurate illustrations, the structure of their own bodies.”7 The work madeVesalius famous as well as infamous: He incurred the wrath of the Inquisitionand was sentenced to a pilgrimage to the Holy Land, “which, because of theuncertainties of travel at that time, practically amounted to the death penalty;indeed, he never came back from the trip.”8 Once the secrets of nature are revealed, they cannot be ignored. Physiciansand lay persons alike began to view the human body as a machine whose work-ings must be understood, rather than merely manipulated in the tradition ofthe herbal empiricists. The stage was now set for the development of the scien-tific diagnosis of patients, both dead and alive. The diagnosis of live patients is asurprisingly recent development. The first diagnostic method, thoracic per-cussion, was discovered in 1756 by Leopold Auenbrugger (1722–1809), theson of an innkeeper in Graz, Austria. As a youngster, Auenbrugger learned totap caskets of wine to determine the quantity of liquid in the container and ap-plied the technique to the human chest. This simple but ingenious method ledthe famed French physician, René-Théophile-Hyacinthe Laennec(1781–1826) to hit on the idea of thoracic auscultation and, in 1816, to the in-vention of the stethoscope. Although standard thermometric values were de-veloped in the seventeenth century, the systematic measurement of bodytemperature was introduced into medicine only in 1851.9 The development of 5
  27. 27. Pharmacracyan ever-growing array of diagnostic instruments and techniques followedquickly. Today, the practicing physician can diagnose many diseases in the liv-ing patient as objectively and almost as effectively as the pathologist can diag-nose them at autopsy. The long-standing gap between antemortem (clinical)diagnosis and postmortem (autopsy) diagnosis has narrowed but has not dis-appeared. Despite modern diagnostic techniques, the postmortem examina-tion of the cadaver remains an indispensable tool for scientific medicine andforensic pathology. After steady advances in anatomy and physiology, the dawn of the nine-teenth century found European and American society confronted with a di-lemma. As medical schools multiplied, the demand for corpses as instructionalmaterials for students and surgeons escalated. Because the legal supply of ca-davers was unable to meet this demand, a brisk business in black market cadav-ers arose. “Resurrectionists” dug up recently interred bodies and evenmanufactured cadavers by “euthanizing” vagrants. In 1831, the Common-wealth of Massachusetts, and in 1832, the British Parliament passed theso-called “Anatomy Acts,” which permitted the use of unclaimed bodies fordissection by specially licensed teachers. Although the development of the modern, scientific concept of disease wasa gradual process, the publication, in 1858, of Cellular Pathology as Based uponPhysiological and Pathological Histology, by Rudolf Virchow (1821–1902), isgenerally accepted as signaling the birth of modern medicine as a professionbased on empirical science. The study of pathology as the phenomenology ofdisease, combined with the study of bacteriology as the etiology of infectiousdisease, placed medicine as the study of bodily disease on the rock-solid founda-tion of modern science. From Gnosis to Diagnosis: Cui Bono? Textbooks of medicine, and especially of pathology, treat diseases as defectsand malfunctions of the human body, “bad things” that no “sane” personwould wish upon himself. Viewing disease existentially reveals a different land-scape. People often assert that they are ill or that another person is sick. It is anerror to believe that people say these things only because they have a disease oronly because the person they call sick has a disease. People are often sick but donot say so or say so only to a few confidants, and they often assert, for a varietyof reasons, that others—about whom they know next to nothing—are sick:thus, people simulate illness or malinger (to avoid military service), simulatehealth or deny illness (to avoid medical attention), and claim that others aresick by diagnosing them (to justify treating them as patients). These elemen- 6
  28. 28. Medicinetary truths have not been lost on artists, who provide us with perceptive ac-counts of the often complex and devious motives of patients and doctors.10 Having a demonstrable disease is not enough to explain why the subject as-serts that he is ill (assumes the sick role) or why others assert that he is ill (placehim in the sick role). To understand the myriad nonmedical meanings andconsequences of illness—that is, the tactical rather than descriptive uses ofterms such as “ill” and “patient”—we must, at least temporarily, ignore thepathological dimensions of the concept and instead focus on the classic prob-lem, Cui bono? Cicero explained the importance of posing this question, pri-marily to oneself, as follows: “When trying a case [the famous judge] L. Cassiusnever failed to inquire, ‘Who gained by it?’ Man’s character is such that no manundertakes crimes without hope of gain.” (“L. Cassius . . . in causis quaereresolebat ‘cui bono’ fuisset. Sic vita hominum est, ut ad maleficium nemo conetur sinespe atque emolumento accedere.” Marcus Tullius Cicero, 106–43 B.C.)11 No man asserts that he or someone else has an illness without hope of gain.The potential gains, for oneself or others, from asserting such a claim—for ex-ample, securing medical help, monetary compensation, excusing crime, and soforth—are virtually endless. They depend on the claimant’s character and mo-tives, the social context in which the claim is advanced, and the ever-changinglegal and social milieu in which medicine is practiced. In this book, I shall use the terms “disease,” “discomfort,” and “deviance” inspecific and distinct ways. Disease refers to a demonstrable alteration in thestructure or function of the body as a material object considered harmful to theorganism, for example, a cancerous lesion or paralysis as a result of a stroke.Discomfort denotes the complaint of an individual about his own body andbehavior, for example, pain, fatigue, or depression. Finally, deviance identifiesthe complaint of individuals about the behaviors of other persons or groups,for example, the habitual use of legal or illegal drugs, illegal sexual behavior, orbehavior causing injury or death to others or the self. If we count discomforts and deviances as diseases, we change the criterionfor what counts as a disease and set the ground for steadily expanding the cate-gory called “disease.” Patients suffering from discomforts can classify their feel-ings of malaise as diseases and can try to convince others to accept their claims.Many prominent persons now engage in this kind of disease promotion: someadvertise their depression as a brain disease, others their impotence as ED(erectile dysfunction), still others their former drug use from which they are “inrecovery.” Physicians and politicians can do the same with other people’s devi-ance. Because physicians and politicians regularly function as agents of thetherapeutic state, this is an ominous development: acting in concert, they pos-sess the power needed to convince, coerce, co-opt, or corrupt the public to ac-cept the illness inflation they promote. 7
  29. 29. Pharmacracy This process of illness inflation—or, more precisely, diagnosis infla-tion—began in the seventeenth century with the postmortem diagnosis of sui-cides as non compos mentis, hence excusable for their felonious deed ofself-murder.12 It gathered speed in the eighteenth and nineteenth centurieswith the medicalization of crime and sex, exemplified by the popularization ofthe insanity defense, the hospitalization of the insane, and the fabrication of di-agnoses such as masturbatory insanity.13 And it is now running amok, virtuallyevery wrenching personal experience and socially undesirable behavior beingdiagnosed as a disease and discovered to be treatable by an intervention classi-fied as health care. 8
  30. 30. 2 SCIENTIFIC MEDICINE Disease Scientific medicine has as its object the discovery of changed conditions characterizing the sick body or the individual suffering organ. Rudolf Virchow (1821–1902)1 The necropsy is, and remains, the final, crucial, common pathway in “dis- ease.” . . . [It] is of fundamental importance and irreplaceable in medical science. Alvan R. Feinstein (1967)2 When patients die, autopsy is considered to be the optimal standard to confirm clinical diagnoses. John Roosen et al. (2000)3Before there was science, there was religion, and before there was scientificmedicine, there was magical medicine. For a long time, people attributed med-ical powers to priests, the priests believed they possessed such powers, and thetemporal rulers legitimized priests as effective healers. Today, people tend to at-tribute near-magical powers to physicians, many physicians believe they pos-sess such powers, and the state legitimizes physicians as effective healers. Whatcounts or ought to count as a disease (or treatment) forms no part of these sys-tems of belief. Magical medicine men—from primitive shamans with painted faces tomodern charlatans puffed on television—can cure diseases they can neither
  31. 31. Pharmacracyclearly define nor objectively identify. Scientific medicine men—exemplifiedby the pioneer pathologists who sought to define and objectively identify dis-ease, before trying to explain it, let alone trying to remedy it—promise no suchmiracles. We must not lose sight of this ironic disjunction between knowingwhat a disease is, and knowing how to relieve the patient of suffering; if we for-get it, we are likely to yield to the temptation to think of disease in terms of itbeing “treatable,” by an officially accredited expert, by an officially accreditedmethod. John Selden, a seventeenth-century English jurist and scholar, warned:“The reason of a thing is not to be inquired after, till you are sure the thing itselfbe so. We commonly are at, what’s the reason for it? before we are sure of thething.”4 If we fail to heed this principle, we risk “explaining” a troubling phe-nomenon—for example, the plague or schizophrenia—without knowing pre-cisely what the thing is that we are explaining.THE CONCEPT OF DISEASE The concept of disease as an affliction of living organisms is probably as oldas civilization. With the dawn of human consciousness, people must have no-ticed that plants, animals, and human beings sometimes change their appear-ance, lose their normal functions, wither, and die. They also must have noticedthat this process often affects many of the same organisms at the same time orin rapid succession. Consider the following scriptural account of an epidemiccreated deliberately by a kind of bacterial warfare: “And the Lord said unto Mo-ses and unto Aaron, Take to you handfuls of ashes of the furnace, and let Mosessprinkle it toward the heaven in the sight of Pharaoh. And it shall become smalldust in all the land of Egypt, and shall be a boil breaking forth with blains uponman, and upon beast, throughout all the land of Egypt.”5 Whether this epidemic, affecting both man and beast, was anthrax is specu-lation, but it may well have been. Anthrax is one of the oldest known diseases ofanimals; its manifestations were recorded by Homer, Hippocrates, Galen, andPliny.6 The microbe Bacillus anthracis can infect dogs, cats, cattle, sheep, goats,horses, mules, and swine. It is the first infectious disease against which a vac-cine was developed, by Louis Pasteur in 1881. Ever since antiquity, historians have recorded plagues destroying armies andcities; leprosy and venereal diseases have long been understood to be “conta-gious,” that is, spread by human contact.7 People grasped the idea of contagionlong before the discovery of microscopic organisms. What people did notgrasp, even long after their discovery, was that these organisms could harm hu-man beings. 10
  32. 32. Scientific Medicine People abhor being baffled by the dangers that face them. Preferring a falseexplanation to none, most people want, and are relatively easily satisfied with,any “plausible” explanation for everything they fear. Thus, people knew, orthought they knew, that the plague was caused by demons, witches, the break-ing of taboo, the evil eye, humoral imbalance, Jews poisoning wells, and soforth, and that it could be cured by exorcism, aspersion of holy water, bloodlet-ting, worthless herbal medicine, and so forth. One reason for the late develop-ment of the scientific concept of disease was, as I noted earlier, the readyavailability of false explanations; another was the lag in the application of sci-ence to medicine.8 The Core Concept of Disease: Somatic Pathology Religion tells us that the mortal human body is a vessel, given to us by God,to house our immortal soul. Science tells us that the body is a biological ma-chine that we inhabit and use, but whose structure and function we do notfully understand. This perspective—which makes it plausible to compare un-derstanding the makeup of the body as a machine and fixing its breakdowns tounderstanding the makeup of a complex man-made machine and fixing itsbreakdowns—has profound implications for the concept of disease and formedicine as science and technology. We know how to use cars, computers, television sets, and many other ma-chines, without necessarily understanding their internal structures and func-tions, let alone knowing how to fix them when they break down. However,there are experts who know how to make and repair such machines. Those ex-perts need precise definitions for certain terms for practicing their craft compe-tently, and it is they who typically define the meaning of terms that refer toobjects or practices used in their daily work. For example, the word “muffler”means one thing to an auto mechanic and another thing to a haberdasher. Thesame goes for the word “disease.” For pathologists, disease is a bodily lesion,something they can observe, objectively demonstrate, perhaps even deliber-ately reproduce. For practicing physicians, it is the malady from which theythink the patient suffers. For patients, disease is the condition to which they at-tribute feeling unwell. For psychiatrists, politicians, journalists, and peoplegenerally, it is all of the above and anything else they want to make it. Each of these concepts has its proper place. But only the pathologist’s con-cept of disease is relevant to the scientific definition of disease as a departurefrom normal bodily structure and function. “All illnesses,” writes Stanley L. Rob-bins, the author of a standard textbook of pathology, “are expressions of cellularderangements.”9 This concept is indifferent to the condition’s cause, the af-fected organism’s feelings or wishes about it, or society’s legal and political atti- 11
  33. 33. Pharmacracytude toward it. For example, a malignancy, say cancer of the lung, is not adisease because the patient coughs up blood (a sign of disease); and an injury,say whiplash as a result of a traffic accident, is not a disease because it results indisability and is a source of monetary compensation (consequences of disease).René Leriche (1874–1955), famous French surgeon and founder of modernvascular surgery, was right when he observed, with something of a rhetoricalflourish: “If one wants to define disease it must be dehumanized. . . . In disease,when all is said and done, the least important thing is man.”10 In this connection, it cannot be overemphasized that while a particular pat-tern of behavior may be the cause or the consequence of a disease, the behavior,per se, cannot, as a matter of definition, be a disease. Boxing or drinking alcoholmay cause diseases but are not diseases. Disability—the inability to earn a liv-ing or care for oneself—may be, or may not be, a consequence of disease, but isnot a disease. The importance of a purely materialist-scientific definition of disease is per-haps best appreciated by comparing it to the purely materialist-scientific defi-nition of, say, carbon. The carbon atom has certain specific physical propertiesthat distinguish it from every other element. Those properties are physical, noteconomic or technological. Coal and diamond are two kinds of carbon, muchas diabetes and diphtheria are two kinds of disease. To the untrained eye anduninformed mind, these phenomena are grossly dissimilar. Yet, to the trainedeye and informed mind, they are members of the same class: carbon and dis-ease, respectively. The economic value or social uses of coal and diamond are not relevant tothe concept of carbon, as a term of scientific discourse. We do not infer what asubstance is from its value or use. Gold, like diamond, is valuable and used asjewelry, but we do not infer from this that it is composed of carbon. Similarly, the therapeutic implications of diabetes and diphtheria are notrelevant to the concept of disease, as a term of scientific discourse. We do not, asa rule, infer what a disease is from its response to treatment. Like diabetes, de-pression—psychiatrists say—is “treatable.” That does not entitle them toclaim that depression is a disease. (Diabetes was, of course, a disease before itwas treatable.)RUDOLF VIRCHOW: IDENTIFYING DISEASE Medical historians view Virchow (1821–1902) as the Newton (1642–1727)of scientific medicine. Emanuel Rubin and John L. Farber, the authors of thetextbook Pathology, state: “Rudolf Virchow, often referred to as the father ofmodern pathology . . . propos(ed) that the basis of all disease is injury to thesmallest living unit of the body, namely, the cell. More than a century later, 12
  34. 34. Scientific Medicineboth clinical and experimental pathology remain rooted in Virchow’s cellularpathology.”11 Alvan R. Feinstein, professor of medicine at Yale medicalschool, declares: “Virchow’s work was magnificent, laying the foundation onwhich modern histopathology still rests, and demolishing the erroneous doc-trine of humoral causes for disease.”12 David M. Reese, an oncologist at theUniversity of California at Los Angeles, writes: “Like Newton’s Principia twocenturies earlier, the work [Virchow’s Die Cellular- pathologie] caused an im-mediate sensation in Europe. Theories about disease now could be unified un-der a single rubric, the concept of the cell and its normal and pathologicalfunctioning.”13 The identification of disease as a physical-chemical phenomenon is contin-gent—as is the identification of any other such phenomenon—on the methodof observation available to the investigator. For the pioneer anatomical patholo-gists, disease was an abnormal organ visible to the naked eye. The microscopeand tissue-staining techniques enabled physicians to examine tissues and cellsand led to the distinction between anatomy and histology, gross pathology andmicroscopic pathology (histopathology). With the development of each newtechnology—from the x-ray and electrocardiograph to chemical and serologicaltests—the methods used to detect disease were widened: The detec-tion-identification of disease may thus be morphological, histological, radiologi-cal, chemical, serological, and so forth. However, the criterion of disease remainsthe same: functional or structural abnormality of cells, tissues, or organs. In thisbook, I repeatedly contrast bodily diseases with so-called mental diseases, whichI classify as nondiseases. Because the mind is not a bodily organ, it can be dis-eased only in a metaphorical sense. Since there is no objective method for detect-ing the presence of mental illness, there is also no such method for establishing itsabsence. The claim that a mental illness is a brain disease is profoundlyself-contradictory: a disease of the brain is a brain disease, not a mental disease. Medical scientists are, of course, not satisfied with identifying diseases; theywant to identify their causes as well. Besides chemical and physical injuries, themost obvious causes of disease are infections. As a result, the scientific identifica-tion of disease has always been partly descriptive and partly explanatory. The di-agnosis “squamous cell carcinoma” is an example of a descriptive diagnosticterm, requiring microscopic examination of the tissue for definitive identifica-tion, whereas the diagnosis “vitamin C deficiency”—which replaced the term“scurvy,” a descriptive diagnosis—is an etiological diagnostic term. Disease as Cellular Pathology The definition of disease as cellular pathology is an idea that, as medical his-torian Erwin H. Ackerknecht put it, “has dominated biology and pathology up 13
  35. 35. Pharmacracyto this very day.”14 Why was this idea so fundamental to the development ofmedicine as a science? Because prior to the cellular-pathological concept of dis-ease, there were many theories of disease, so-called “systems.” However, nonewas based on empirically verifiable observations or served the interest of ad-vancing knowledge; instead, each served the interests of its promoter, creatingfamed healers and founders of systems, such as Galen and Paracelsus, Mesmerand Freud. This model of disease theorizing continued after Virchow in thefield of psychiatry, exemplified by the system created by Emil Kraepelin and itsprogeny, the periodically revised versions of the American Psychiatric Associa-tion’s Diagnostic and Statistical Manual of Mental Disorders (DSMs). Born in a small town in Prussia, trained as a physician, Virchow’s first jobwas dissecting corpses at the morgue of the Charité, the prestigious, municipalteaching hospital in Berlin. His concept of disease was firmly anchored in thecontext of that experience. Disease was not what the patient complained of,nor was it what the physician at the bedside observed. Disease was not definedin terms of its cause or cure. Instead, it was identified in terms of what the pa-thologist could detect in cells, tissues, and organs, at autopsy or, in the case ofthe living person, in a biopsy specimen surgically removed from his body. Virchow’s concept of disease was thus phenomenological, in the scientific,not the philosophical, sense of that word. In 1845, when Virchow was onlytwenty-four years old and barely two years after receiving his medical degree,he formulated the idea that was to become the core concept of disease. In an ad-dress titled “On the Need and Correctness of a Medicine Based on a Mechanis-tic Approach,” he argued that “the goal of modern medicine should be toestablish firmly a physics of organisms according to mechanical laws, with the cellas the organic molecule, analogous to the chemical or physical atom.”15 By observ-ing an apple falling to the ground, Newton identified and defined gravity. Byobserving “abnormal” cells, tissues, and organs, Virchow identified and de-fined disease. The apple has no opinion about gravity. The cadaver or the pa-tient’s body has no voice about disease. We have forgotten this simple fact andare paying dearly for our amnesia. When we treat medicine as a science, similar to the hard sciences, the impli-cations are far reaching. Just as physical science deprived the popes of their au-thority regarding the movement of planets, so medical science deprivespatients—as well as priests and politicians—of their authority regarding thedefinition, nature, cause, and cure of disease. This development is not some-thing to regret, but something to celebrate. Authority over the scientific defini-tion of disease must not be confused with authority for judging the ethics ofmedical interventions or the power to provide or prohibit such interventions. As noted at the head of this chapter, in Virchow’s view the object of scientificmedicine is “the discovery of changed conditions, characterizing the sick body 14
  36. 36. Scientific Medicineor the individual suffering organ.” To this he added that “its foundation is thusphysiology.”16 As a science, medicine qua pathology is thus materialistic.Virchow put it thus: “This science [pathology], which naturally includes a cel-lular theory of the living, proceeds from the fact that cells are the actual opera-tive parts of the body. . . . The same substance [cells], which is the bearer of life,is also the bearer of sickness. Every spiritualistic impulse is excluded.”17 Virchow anticipated the confusion, common today, between disease per seand the etiology of disease as contributory cause (along with the host organ-ism’s reaction to it), but not disease per se: “It thus happens, as I have repeatedlyset forth, that there is the confusion of a being with a cause, of an ens morbi witha causa morbi. An actual parasite . . . can be the cause of a disease, but it cannever exhibit the disease itself.”18 Cancer of the lung is a disease. But smok-ing—even if diagnosed as “nicotine dependence” or “substance abuse”—is notand cannot be a disease, just as a microorganism per se is not and cannot be adisease. Virchow never deviated from the concept of disease as phenomenon, inde-pendent of its etiology or explanation. “The secret of disease,” concluded med-ical popularizer Rene Dubos, “appeared to reside in the anatomy of thetissues.”19 It was not only the secret of disease that resided there, its definitiondid as well. Virchow as Social Activist The publication of Virchow’s Cellular Pathology in 1858 established “hisreputation as the founder of a new scientific discipline.”20 What scientific dis-cipline? Medicine as a science. However, medicine was then, and is now, a per-sonal service as well as a scientific activity. The service component—which wecall “clinical medicine” or “medical practice” and which often overshadows thescientific foundation of medicine—is not, and cannot be, a science. Why? Be-cause its goal is to increase the well-being of the patient, whereas the goal of sci-entific medicine is to increase our knowledge about the nature of the humanbody in health and disease. The well-being of the patient is not a fact, but anopinion or judgment, not necessarily the patient’s; it may be the opinion of aparent or guardian, a judge, or a health maintenance organization (HMO).Thus, while the valuation of disease as something undesirable is central to theclinical concept of disease, it is only peripheral to its scientific concept. (Theprefix “dis” is not merely descriptive but also, eo ipso, negatively valuative.) Although Virchow was a superb observer, by temperament he was not a re-clusive scientist, satisfied with exploring a limited aspect of the world fromwithin the sanctuary of his laboratory. Recognizing what was obvious then andis obvious now, namely, that poor people are more likely to be afflicted with 15
  37. 37. Pharmacracydiseases than rich people, Virchow became a medical and social revolutionaryin the fashion of the French philosophes.21 He fought against the alliance of thechurch and the state and wanted to replace it by an alliance of science, espe-cially medicine, and the state. The abolition of poverty by politics and of igno-rance by education promised a utopian future. Indeed, it was Virchow who, in1873, coined the term Kulturkampf—literally, struggle for culture, here usedto refer to the conflict between the secular-scientific and religious-mysticalworld views and, more specifically, to the political struggle against the influ-ence of the Catholic church in Prussian politics: “He sincerely believed that thechurch . . . was incompatible with modern natural science and indeed withfundamental principles of freedom, tolerance, and rationality that had beenthe foundations of secular society in Western Europe since the Enlightenment.. . . He boldly stated that in the modern age science rather than religion wouldprovide the basis for morality.”22 A political naif, Virchow had not the slightest understanding of the depend-ence of individual liberty on the security of property, the rule of law, and thechecks that, in a secular society, the church and other informal organizationsprovide against unlimited state power. Thus, not only was Virchow thefounder of the scientific concept of disease, he was also an early and enthusias-tic supporter of the therapeutic state. Unaware that treating certain aspects ofthe human condition as if they were diseases is full of pitfalls, he agitated for“school hygiene” and declared that “the whole penitentiary system was . . . ac-tually a public health problem. Punishment should be replaced with psychiat-ric education.”23 In 1871, after the defeat of the French in the Franco-Prussian war, Virchowclaimed that the war had been “forced on Prussia” and quoted approvingly theopinion of the German psychiatrist Karl Stark, “that at the time the war brokeout the French might have been gripped by some form of collective insanity.”24These remarks foreshadow the denunciation—couched in a diagnostic vocab-ulary—of Jews as genetic degenerates, of Hitler and other despots as psycho-paths, and similar semantic assaults masquerading as medical diagnoses.Evidently, it never occurred to Virchow that medical statism could be just as in-imical to individual liberty as religious statism. With respect to mixing science and theology, Virchow’s scientific convic-tions served him well. In 1868, a Belgian novitiate was supposed to have mirac-ulously survived for three years with “no sustenance except water and thecommunion host.” Asked by the Vatican to examine the woman and render anexpert medical opinion about the claim, Virchow recognized that there wasnothing to examine and refused.25 However, his scientific convictions failedhim with respect to mixing science and politics: his compassion for the poor 16
  38. 38. Scientific Medicineled him to flirt with medical statism, and his desire to please authority contrib-uted to his worst blunder as a scientist. Shortly before becoming emperor for the last ninty-nine days of his life,Crown Prince Frederick III (1831–1888) complained of hoarseness. His phy-sician found a small growth on one of his vocal cords and treated it withelectrocoagulation. Soon the growth recurred and malignancy was suspected.Surgical excision of the tumor, requiring removal of the larynx, was consideredlife-threatening and, even if successful, would have resulted in the loss of hisvoice, incapacitating him for the role of emperor. To resolve the dilemma andsince the crown princess was English, the most prominent English throat spe-cialist, Dr. Morell Mackenzie, was called for consultation. Dr. Mackenzie de-cided that a correct diagnosis required examining a biopsy specimen of theaffected tissue. Naturally, the task of examining the tissue and rendering a finaldiagnosis fell upon the shoulders of Rudolf Virchow, the most famous patholo-gist in the world. Mindful of political power, Virchow, it appears, did not wantto be the bearer of a fatal prognosis: “He declared that all of the growth was lo-cated on the surface . . . unlike malignancies. . . . Labeling the illnessPachydermia laryngis vericosa [a wart on the larynx], he said that the generallyhealthy condition of the tissue gave a very good prognosis.”26 As a result, Mac-kenzie had no reason to remove the tumor. The lesion was malignant. Threemonths later Frederick was dead. The autopsy, conducted by Virchow in thepresence of Mackenzie and the emperor’s personal physicians, revealed that“the larynx was completely destroyed through cancer and putrid bronchitis.”27Recriminations among the physicians who had attended the emperor now en-sued, Virchow being accused of failing to examine the patient, confining him-self to examining only the biopsy specimen. Virchow in turn accusedMackenzie of having taken the biopsy from the healthy part of the larynx. Inthe end, Virchow escaped with his reputation unblemished.LOUIS PASTEUR: EXPLAINING DISEASE Understanding Pasteur’s contribution to medicine as a science requires thatwe recapture the pre-Darwinian scientific view regarding the nature of livingmatter. Before biology could become a science, biologists had to answer thequestion, What is the origin of life? The biblical answer was that God createdall things, nonliving and living, including man. The scientific answer, in Pas-teur’s day, was called “spontaneous generation”; that is, under certain condi-tions not yet understood, living organisms arose “spontaneously” fromnonliving matter: “Under a thousand symbols, men of all religions and philos-ophies have sung and portrayed the repeated emergence of life from inanimate 17
  39. 39. Pharmacracymatter.”28 This idea, now as discredited as the idea that the earth is flat, was ar-dently supported by Pasteur’s contemporaries. Disease and the Struggle for Life Since earliest times, people must have recognized that many animals live offother animals. Wrote Jonathan Swift (1667–1745): “So, naturalists observe, aflea / Has smaller fleas that on him prey; / And these have smaller still to bite‘em; / And so proceed ad infinitum.”29 Anthropologists believe that the initialimpetus for civilization through cooperation may have been man’s desire toavoid becoming food. People must have also recognized that once living beings die, their remains“turn to dust,” as the Bible phrased it. How does that happen? It happens bydead bodies becoming food for animals that require “living matter” for suste-nance, for example, vultures feeding off carrion. It remained for Pasteur todemonstrate that this process—animals “eating” other animals—occurs on amicroscopic level as well. He thus brought home to mankind—and especiallyto medical scientists—that human beings are consumed not only by animalswe can see with the naked eye but also by “animals” we cannot see without theaid of the microscope. This laid the ground for formulating the fundamentaletiological core of the concept of disease—namely, the destruction of the bodyof a living host (plant or animal) by pathogenic microorganisms. In hindsight,this discovery came astonishingly late in the history of science. Using a microscope, the great Dutch naturalist Anton Leeuwenhoek(1632–1723) had demonstrated the existence of microorganisms—“little ani-mals”—seemingly everywhere in nature. However, for nearly 200 years, thisdiscovery made no impact on physicians. The anatomist pioneers of modernmedicine were interested in identifying lesions that correlated with clinical dis-eases; they were not concerned with the etiology or pathogenesis of disease.This underscores how far we have moved in the opposite direction: today, lead-ers in medicine are far more interested in naming a cause—for every aspect ofthe human condition—than in finding a new lesion. The understanding ofdisease as a biological—chemical and microbial—process had to wait until1857, when Pasteur published his seemingly unrelated classic studies on fer-mentation. To grasp the nature of light as both corpuscular and wave-like, physicistshad to reject the existence of the ether—that is, the notion that space is filledwith minute invisible particles of matter. Similarly, to grasp that life can ariseonly from living matter, biologists had to reject the existence of spontaneousgeneration—that is, the notion that life can arise, de novo, from nonlivingmatter. By the same token, to grasp the nature of human conflict and its poten- 18
  40. 40. Scientific Medicinetially horrifying consequences, we must reject the notion that (unwanted) be-havior can be a real disease. Pasteur was not a physician. He had no medical training whatever. Pasteurwas a chemist who spent the first ten years of his scientific career, from 1847 to1857, laying the groundwork for the field known as stereochemistry. He be-came one of the founding fathers of scientific medicine by a lucky acci-dent—being asked to solve the problem of silkworm disease. Luck, however, ashe later remarked, “favors the prepared mind.” Along with cotton and wool, silk had long been one of the most useful fibersknown to man. The material comes from the secretion of the mulberryleaf-feeding silkworm, Bombyx mori, a family of Lepidoptera that includeslarge moths and butterflies. The mature caterpillar produces a clear, viscousfluid called fibroin, which, in combination with another fluid called sericin,forms the solid filaments of silk that make up the cocoon. Silk has been used since antiquity. Long before Pasteur’s time, many coun-tries, including France, had flourishing silkworm industries. People who madea living cultivating silkworms were familiar with the fact that silkworms some-times failed to develop proper cocoons and hence yielded little or no usable fi-bers. No one knew what caused the problem, called “disease of silkworms”(pébrine, in French), nor did anyone have a remedy for it. The only thing thegrower affected by this problem could do was to destroy the affected wormsand start all over with batches of healthy worms. As is usually the case with au-thorities who have no understanding of a problem, the experts had many ex-planations for silkworm disease, ranging from poor-quality mulberry leaves toimproper humidity and temperature levels in the silkworm incubators. Actually, an amateur scientist in Italy, Agostino Bassi (1773–1856), had dis-covered the cause and nature of silkworm disease more than twenty years be-fore Pasteur rediscovered it. In 1853, Bassi published his classic monograph,Del Mal del Segno30 (the Italian name for silkworm disease), showing that theailment was infectious, caused by a microscopic parasitic fungus transmittedfrom one silkworm to another by direct contact or through infected food. Bassi was trained as a lawyer but, like many great nineteenth-century scien-tists, his health was said to be too poor to permit him to practice his profession.However, he lived to be eighty-three and spent his life as a gentleman scholar.Although he lacked training or even interest in medicine or veterinary science,he—more than Pasteur or Koch—is the true father of the germ theory of dis-ease. Because Bassi was an amateur, during his lifetime his discovery was ig-nored by experts on silkworm disease as well as by medical scientists. After hisdeath, his work was overshadowed by that of Pasteur, Robert Koch, and theother pioneers of bacteriology. The Encyclopaedia Britannica devotes only two 19
  41. 41. Pharmacracybrief paragraphs to Bassi’s life and his work. However, the organism he discov-ered is named Botrytis bassiana. By the middle of the nineteenth century, the French silkworm industry wasvirtually in ruins. Silkworm disease spread to Italy, Spain, and Austria, andeventually to China and Japan. In 1865, Jean Baptiste André Dumas(1800–1884)—one of the world’s preeminent chemists—requested and re-ceived authorization from the Minister of Agriculture to appoint a mission tostudy pébrine.31 Dumas, who had been Pasteur’s teacher and scientific mentor,asked his pupil to investigate the problem. Until that day, Pasteur had neverseen a silkworm or a mulberry tree, the leaves of which served as food for theworms. As legend has it, Pasteur—who knew nothing about the subject andevidently wanted to demur—inquired: “Is there then a disease of silkworms?”To which, Dumas replied: “So much the better! For ideas you will have onlythose which shall come to you as a result of your own observations!”32 When Pasteur undertook to investigate the disease, he had already made amonumental discovery that proved extremely useful. It had long been knownthat when organic matter is left alone, it undergoes a seemingly spontaneoustransformation. Why and how this happened, however, was not known. Un-derstanding the process was hampered by its having two different names: if itinvolved the conversion of sugars and starches into alcohols, it was called “fer-mentation,” but if it involved the decomposition of proteins into foul-smellingproducts, it was called “putrefaction.” We still use these terms. But, thanks toPasteur, we now understand that the production of beer and the production ofpus rest on similar principles and processes. Knowing that something occurs or making use of that knowledge is a far cryfrom understanding how and why it happens. That was the case with fermenta-tion and putrefaction until Pasteur came along. Since antiquity, people knewhow to make bread from starch, and wine from grape juice. Because these pro-cesses are accompanied by the formation of carbon dioxide gas causing bub-bling in the product, bread and wine became the symbols of life. People also knew that organic matter decomposed, dead bodies turning todust. It was to combat this process that ancient Egyptians developed the art ofembalming. However, it is unlikely that they realized that if dead plants andanimals did not decompose—becoming a part of the soil, the air, and the wa-ter—their remains would soon cover the surface of the earth. It remained forPasteur to discover that fermentation and putrefaction are similar chemicalprocesses, each depending on a catalyst, yeast, that is necessary for, but is not anactive participant in, the reactions. After studying the problem for six years, in 1861 Pasteur reported that fer-mentation and putrefaction were both caused by living organisms. This dis-covery spelled the doom of the theory of spontaneous generation, a sacrosanct 20
  42. 42. Scientific Medicinedoctrine that had hobbled the development of biology for centuries. In thecourse of arriving at this conclusion, Pasteur made another basic discovery: Heshowed that many biochemical processes are anaerobic; that is, they can occuronly in the absence of air (oxygen). He observed that although the yeast organ-ism necessary for fermentation grows most rapidly in the presence of air, it pro-duces fermentation most efficiently in its absence. These discoveries gainedPasteur the recognition he so richly deserved. The term “pasteuriza-tion”—identifying the process of preventing unwanted fermentation (“spoil-age”) by controlled heating—has become a verb in virtually all modernlanguages. What, exactly, is the relevance of fermentation to disease? Dubos answeredthe question as follows: The concepts dealing with fermentation and contagious diseases fol- lowed a parallel evolution during the two centuries which followed Boyle’s statement. In both cases, two opposite doctrines competed for the explanation of observed phenomena. According to one, the primary motive force—be it of fermentation, putrefaction, or disease—resided in the altered body itself, being either self-generated or induced by some chemical force which set the process in motion. According to the other doctrine, the process was caused by an independent, living agent, foreign in nature and origin to the body undergoing the alteration, and living in it as a parasite. It is the conflict between these doctrines which gives an in- ternal unity to the story of Pasteur’s scientific life.33 Thus, when Pasteur undertook to investigate silkworm disease, he was men-tally prepared to assume that it might be caused by a microorganism, which isprecisely what he found. By examining the silkworm eggs under a microscope,infected eggs could be easily separated from uninfected eggs, preventing theproduction of additional diseased worms and the perpetuation of the disease. Pasteur’s discovery of the nature of silkworm disease had a powerful impacton shaping the scientific concept of disease. The idea that disease is a loss of nat-ural function antedates modern medicine. Pasteur demonstrated that certainabnormalities of the organism’s body, identifiable with the aid of the micro-scope, may be consistently associated with, and be the markers of, disease. Theeggs of diseased silkworms could be easily distinguished from the eggs ofhealthy silkworms. This understanding was of no help for curing the malady,but it enabled breeders to prevent the disease by identifying and discarding in-fected eggs and selecting only healthy eggs for breeding. It bears emphasizing that, in Pasteur’s hands, the identification of diseasedsilkworm eggs began and ended as an ordinary, commonsense process, rather 21
  43. 43. Pharmacracythan as a specialized scientific procedure. To be sure, understanding the diseaseas a microbial infection was a scientific discovery. However, once that was ac-complished, Pasteur made both the diagnosis and the prevention of the diseasea commonsense procedure whose mastery required only a simple skill, easilylearned by anyone who wished.DISEASE AS FACT, DISEASE AS JUDGMENT Once it was recognized that microorganisms could cause disease in silk-worms, it was easy to conclude that they might also cause disease in human be-ings. “The very use of the word ‘diseases’ (maladies) to describe thesealterations,” Dubos observed, “rendered more obvious the suggestion that mi-croorganisms might also invade human and animal tissues, as they had alreadybeen proved to do in the case of silkworms.”34 The process of animal A feeding on animal B is simply a fact we observe.The element of value enters the picture if we intervene or wish to intervene. Forexample, we can help B by protecting him from being eaten by A: in effect, thisis what we do when we take an antibiotic. Penicillin is therapeutic for the pa-tient (whom we want to save), but is toxic for the microorganisms (that wewant to destroy). Or, we can help A by providing it with an ample supply of B:this is what we do when we breed animals to feed people. Raising chickens invast factories is good for us: it provides us with a source of abundant, nutritiousfood. But the enterprise is bad for chickens: it creates huge numbers of them,raised in cramped quarters, for the sole purpose of being eaten. The image of illness as a combat, with the victorious animal eating his vic-tim, dramatizes the element of valuation intrinsic to the concept of disease. Itwas this image that impressed itself on Pasteur’s mind, guided all of his medicalwork, and inspired him to suggest that “septicemia may be termed a putrefac-tion of the living organism.”35 Actually, the evaluative element in the concept of disease is self-evident. Pas-teur was commissioned to work on silkworm disease for a practical reason—tohelp the silkworm industry to be profitable. The motive for this pioneeringpiece of medical research was commercial, not compassion for human suffer-ing or disinterested scientific curiosity, let alone the desire to cure sick silk-worms. The understanding of the mechanism of human diseases thus began withthe search for controlling certain biological processes that resulted in the de-struction of property, specifically, animals and plants useful to man—such asanthrax affecting cattle and sheep and phylloxera affecting vine-producinggrapes. In the case of anthrax, the phenomenon we deem to be a disease is astruggle between anthrax bacilli and their host, with the microbes winning. Al- 22
  44. 44. Scientific Medicinethough that account of anthrax is both explanatory and valuative, it is notvalue-dependent in the sense that we call anthrax in cattle a disease solely be-cause we value filet mignon more highly than anthrax bacilli. From a scientific point of view, we could equally well speak of a disease af-fecting anthrax bacilli. In the case of endogenous diseases—say, diabetes or lupus—the valuationlies in the assumption, explicit or tacit, that it is better for a person to live with anormally functioning biological makeup than with a makeup that malfunc-tions, causing disability and death.36 “Health,” observes medical ethicist LeonKass, “is a natural standard or norm—not a moral norm, not a ‘value’ as op-posed to a ‘fact.’ . . . [It is] a state of being that reveals itself in activity as the stan-dard of bodily excellence or fitness relative to each species.”37 Kass correctlyemphasizes that the concept of health piggybacks on the concept of disease,which in turn must be located in the body. Disease reveals itself in the abnormalactivity of the body, not of the person. That the concept of disease contains an element of value judgment does notdiminish the primarily and essentially descriptive, phenomenological characterof the pathological concept of disease. An element of valuation may be presentin certain physical concepts as well. For example, ounce for ounce, helium ismore valuable than iron. This does not affect the phenomenological identifica-tions of helium and iron in terms of the number of protons and electrons intheir respective atoms. Virchow’s achievement is similar. It is important that wedistinguish the negative value attached to a particular disease from the conceptof disease as a phenomenon. If we fail to do so, we are likely to mistake negativevalue for disease and classify as diseases phenomena—unwanted behav-iors—that display no evidence of abnormal bodily structure or function. This isnot a supposition or a warning about a hypothetical danger. It is a descriptionof the present medical-social scene: We are in the midst of galloping diseaseinflation, characterized by an elevation of social judgment to a criterion fordiagnosis. Throughout this book, I maintain that the scientific concept of disease restson objective standards, in principle similar to those of the physical sciences. Inthis chapter I rely heavily on Virchow’s epochal contributions, especially an-choring the scientific concept of disease in the autopsy, that is, the pathologist’spostmortem examination. Some readers may be tempted to find fault with thisreasoning, minimizing or even dismissing Virchow’s work as outdated or evenanachronistic. However, just as Newton’s ideas on the concept of gravity re-main valid and important, so do Virchow’s ideas on the concept of disease. In June 2000, the Mayo Clinic Proceedings published a major study and aneditorial reminding us of and reiterating the pivotal role of the autopsy in sci-entific medicine. The authors, a group of Belgian physicians, compared the 23