Abstract
Medical classification systems aim to provide a manageable taxonomy for sorting diagnoses into their proper classes. The question, this paper wants to critically examine, is how to correctly systematise diseases within classification systems that are applied in a variety of different settings. ICD and DSM, the two major classification systems in medicine and psychiatry, will be the main subjects of this paper; however, the arguments are not restricted to these classification systems but point out general methodological and epistemological challenges of classifying diseases for differing purposes. Deciding what qualifies as a disease to be included into a classification system as well as choosing a specific validator for correctly systematising diseases is complicated because the broad applicability of medical classification systems simultaneously appears as aim and challenge. Drawing upon the case study of classifying Alzheimer’s disease, this paper will address three dilemmas in designing ‘good’ medical classification systems. They are due to general epistemological problems of medicine, such as the relationship between individual manifestations of diseases and the necessity of building groups in order to scientifically elucidate causes of diseases. Moreover, they involve pragmatic issues of designing usable classifications that allow for easily discriminating between classes of diseases, restricting, however, the completeness of disease representations. This paper wants to trace how the choice of certain validators is unavoidably value-laden and deeply intertwined with epistemological assumptions of how different uses relate to each other, resulting either in a prioritisation of (constrained) coherence or of (vague) pluralistic connectibility.
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Notes
It should be noted that psychiatry is not the only medical discipline that makes use of an own classification system. For instance, oncology relies on a very detailed classification system, the TNM Classification of Malignant Tumours (UICC 2009) that stages tumours according to the size and local spread of the primary tumour (T), the number of involved lymph nodes (N) and the abundance of metastases (M). Note also that this system is not uncontested not least because it does not classify the causes of the respective tumour (cf. Debru 1998, Chap. III; Clarke 2011).
See, for example, Rosenberg (2007), esp. Chap. 2, for an historical analysis of the interlacement between the rise of the notion of ‘specific disease entities’, the bureaucratic function of standardised classification systems, and the institutionalisation of evidence-based medicine in the last century.
Cf. the collection of papers in Rothschuh (1975), but also the overviews in Bolton (2008), Murphy (2009) and Paul (2010), to name just a few. It is impossible to review all the relevant literature within this paper, especially since the discussions, even those restricted to western medicine, have been centered on different foci: in the English-speaking world the statistical account of objectively defining disease as deviance from normality (Boorse 1977) is perhaps the most discussed one. In France, the point of departure is usually the critical epistemology of Georges Canguilhem (1989) that focused on the difference between non-normal states and pathological ones due to the ability of biological organisms to adapt to new norms. German debates have circled around the question whether it is possible to formulate a general definition of disease, most prominently considering Rothschuh’s research programme of ‘theoretical pathology’ (cf. Rothschuh 1959; see also Hucklenbroich 2007 and comments in the same issue).
Explicating what we mean by referring to the iridescent term normativity might not only structure debates on normativity in medicine but also unveil the limits of its broad use. For instance, in how far can one compare normativity that is ascribed to an organism (‘biological normativity’) and normativity that refers to socio-cultural norms? For possible interconnections between different conceptions of normativity in the work of Canguilhem and Foucault, see Macherey 2009).
For the notion of ‘warranted oughts’ that are ‘legitimate non-objective ‘oughts’ that depend not on an agent’s (possibly epistemically indefensible) non-normative beliefs but on what the agent is warranted in believing the non-normative facts to be’., see Robertson (2010, 15, his emphasis).
Bowker and Star (2000), alongside Fagot-Largeault (1989) one of the few authors of monographs concerned with ICD’s classification of somatic diseases and causes of death, have made a similar observation with respect to the politics of classification and the negotiation of different interests: ‘Much has been written about the state’s role in classifying and monitoring mental health (…); much less about classifying and monitoring physical health. Yet this latter work has been just as politically fraught and just as imbricated in the rise of the modern state’ (Bowker and Star 2000, 113).
Still, heterogeneity of causes and the complexity of phenotypes are neither necessary nor sufficient for distinguishing mental disorders from somatic diseases. For instance, the well-characterised, monogenetic Huntington’s disease falls into psychiatry. On the other hand, also somatic diseases such as sepsis can form very heterogeneous classes.
But, as I will argue in more detail in ‘Broad Applicability as Aim and Challenge of Classification Design’ by drawing on the case study of AD, the kind of action that shall be informed by classification itself impacts on decisions in classification design and hence issues of ‘assessment’.
As such, descriptive sociological accounts of medicalisation have something in common with descriptive historical accounts of epistemic virtues. Historians of science have pointed out that classifications are designed according to context-sensitive virtues (e.g. inter-rater reliability) of scientific collectives (e.g. Berrios 1999; Daston and Galison 2007).
The specific challenges of scientifically classifying (traits of) human beings and the looping effects (Hacking 1995) classifications have on the classified subjects are fundamental to the epistemological as much as the ethical evaluation of medical classification systems. The realm of this paper is limited to an epistemological perspective and will therefore not further detail the effects classification has on patient’s biographies (but see, e.g. Bowker and Star 2000, Part II).
The influence of (non-epistemic) values in science has received particular attention from feminist philosophers and philosophers of science that are concerned with application-oriented science being subject to ‘the pressure of practice’ (cf. Carrier et al. 2008).
Cf. Fagot-Largeault (2002): ‘Dilemme : ou bien la classification est stable et elle s‘écarte de la réalité naturelle, ou bien elle se veut «naturelle» et… elle est instable’.
Cf, Pantin (1968, 5): ‘The more we restrict the class of phenomena we observe and the number of its variables, the more far-reaching are the possible deductive consequences of our hypotheses. But in so doing much of the grand variety of natural phenomena is systematically excluded from study’.
See Debru (1998), esp. Chap. III, for an in-depth analysis of how scientific strategies have been developed to deal with these problems in the case of leukaemia classification.
It should be noted that recent works in the philosophy of biology have pointed out that what is defined as ‘whole organism’ is not clear by itself and that the boundaries of an organism (e.g. with respect to the in- or exclusion of microbes) are also context dependent (cf., e.g. Dupré and O’Malley 2007; Pradeu 2010).
The case of Lithium being beneficial for treating bipolar disorder was used as a prime argument for the importance to ‘correctly’ diagnose disorders. Especially studies comparing schizophrenia prevalence rates in the US and the UK (cf. Cooper et al. 1972; Pope and Lipinski 1978), unravelling the shortcomings of DSM-II to provide a reliable basis for distinguishing disorders for treatment has highly influenced the general development of the operationalised DSM-III.
On the question if public health is health at all and to what extent the importance of epidemiological research for medicine is compatible with Canguilhem’s concept of individual health, see Giroux (2009).
There are, however, minor updates constantly being incorporated in the systems. The APA has also published a revised text version of DSM-IV, the DSM-IV-TR in 2000.
I will later argue that these features give rise to the necessity of an explanatory pluralism in medicine.
It should be noted that the Diagnostic Criteria for Research (WHO 1993) as well as the Clinical Descriptions and Clinical Guidelines (WHO 1992b) are ‘derived’ from ICD-10: ‘Derived classifications may be prepared either by adopting the reference classification [here: ICD] structure and categories, providing additional detail beyond that provided by the reference classification, or they may be prepared through rearrangement or aggregation of items from one or more reference classifications’ (WHO n.d.). The Primary Care edition is a general simplification and adjustment of the complete ICD-10; the fifth chapter on mental disorders has additionally been published separately only for pragmatic, not conceptual reasons.
It is important to note that these demarcation lines refer to changes of the classification of DAT and AD within DSM and ICD and not to completely new ideas of thinking about dementia in general. In fact, several conceptual questions, such as the role of age, the degree of reversibility of the condition, the possibility to characterise specific neuropathological features and the association to cognitive dysfunctions in order to separate dementia from other psychiatric disorders, that are nowadays addressed within the revision processes of the classification systems, have already been discussed in the nineteenth and early twentieth century (Berrios 1990; Gzil 2009). Yet, as Berrios has stressed, ‘the 1906 debate was not about creating homogeneous diagnoses. It was about the building blocks of neurobiology: whether neurons were independent units (…), or whether staining techniques were reliable, and so on’ (Berrios 1990, 355).
There has been much dispute to what extent the use of different classification systems (viz., ICD, DSM, and specialised Alzheimer’s disease diagnostic criteria published by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association, NINCDS-ADRDA 1984) influences dementia diagnosis and prevalence (cf., Erkinjuntti et al. 1997; Pioggiosi et al. 2003; Wancata et al. 2007; Naik and Nygaard 2008).
Additionally, ‘minor neurocognitive disorders’, a prodrome or mild form of neurocognitive disorder will be classifiable. AD is conceptualised as a subtype for both, major and minor neurocognitive disorder, hence paving the way for integrating research on prodromal stages with medical practice on early diagnosis of late-onset AD.
I take the necessity of explanatory pluralism in medicine to result out of the very nature of diseases. Yet, I think that there are many intersections with other sciences studying complex objects, especially biology (cf. Goldstein 1934; Mitchell 2009). For a defence of a pragmatic, use-dependent approach to classifying in biology resulting in taxonomic pluralism that is compatible with explanatory pluralism, see Dupré (2001). For a detailed argumentation with respect to explanatory pluralism in biology, see Morange (2009), who concludes that ‘[p]erhaps some new explanatory schemes will emerge. But they will not replace the previous ones, but rather add a further level of complexity to this progressive interweaving of explanations’ (Morange 2009, 26). An overview of the current debate on multi-level explanations in psychiatry can be found in Kendler and Parnas (2008).
On Nelson Goodman’s (1955) notion of projectibility see Douglas and Hull (1992, 4): ‘To be useful, a category needs to be projectibile, it must be able to be thrown forwards for prediction about the future, and backwards to a past biography’. Notably, Goodman (1978, Chaps. I, VI and VII) himself was eager to stress that projectibility only works within a specified frame of reference and the truth-value of a ‘kind’ is neither a necessary condition for its projectibility nor a legitimate deduction of it.
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Work for this paper has been supported by a grant of the German Federal Ministry of Education and Research (BMBF, Grant no. 01GP0708). It contains material of my dissertation (in preparation), which is embedded in the German–French Doctoral Programme (funded by the German –French University) of the Philosophy Department of the École normale supérieure in Paris and the Institute for History, Philosophy and Ethics of Medicine at the University Medical Center in Mainz.
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Kutschenko, L.K. In Quest of ‘Good’ Medical Classification Systems. Medicine Studies 3, 53–70 (2011). https://doi.org/10.1007/s12376-011-0065-5
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DOI: https://doi.org/10.1007/s12376-011-0065-5