Skip to main content
SpringerLink
Log in

The overdiagnosis of what? On the relationship between the concepts of overdiagnosis, disease, and diagnosis

  • Scientific Contribution
  • Published:
Medicine, Health Care and Philosophy Aims and scope Submit manuscript

Abstract

Overdiagnosis and disease are related concepts. Widened conceptions of disease increase overdiagnosis and vice versa. This is partly because there is a close and complex relationship between disease and overdiagnosis. In order to address the problems with overdiagnosis, we may benefit from a closer understanding this relationship. Accordingly, the objective of this article is to elucidate the relationship between disease and overdiagnosis. To do so, the article starts with scrutinizing how overdiagnosis can explain the expansion of the concept of disease. Then it investigates how definitions of disease address various challenges of overdiagnosis. The article specifically investigates recent attempts to clarify the relationship between the concepts of disease and overdiagnosis. Several shortcomings are identified and lead to a closer analysis of overdiagnosis in the diagnostic process. Contrary to recent contributions to the field, it is argued that cases of overdiagnosis are not cases of disease. They are non-verified labelling of disease. It is revealed how overdiagnosis establishes an unwarranted link between indicative phenomena, such as polyps or cell changes, and harm, and thereby generates a link to disease. One implication of this study is that we should stop attributing disease language to indicative phenomena. That is, we should stop calling it “cancer screening” when we are actually searching for polyps. Another implications is that we should strive for scientific progress in differentiating phenomena that are of negative value to us from those that are not. In overdiagnosis we diagnose something that is not disease: it is over-diagnosis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Notes

  1. Please note that this is not a comment on the inconsistency of the authors’ claim that overdiagnosis is both “harmless disease” and that it is harmful at the same time (Walker and Rogers 2016, Epub ahead of print). I think that Walker and Rogers will argue that the harm referred to in the definition of overdiagnosis is different from the harm resulting from (the events of) overdiagnosis. The first harm is pathogenic while the latter is iatrogenic and does not stem from the “diagnosed condition.” That is, there are several types of harm from diagnosis and disease, and only the iatrogenic harm is relevant for overdiagnosis.

  2. Although Carter et al. indicate that professionals do not reject realist conceptions of disease (Carter et al. 2016b), they are unclear on this. Altogether, the reference to the professional community is quite vague.

  3. Carter et al. are not clear on the distinction between disease and diagnosis. I will therefore address both and try to clarify the relationship below.

  4. This does not mean that classically structured concepts cannot have definiens that are vague. Here the point is that normativistic conceptions of disease refer to norms and values of some kind, and frequently refer to harm.

  5. There is also another circularity in the “précising definition,” as disease is defined in terms of a person already considered to be a patient, i.e., as “physiological dysfunction that has a significant risk of causing severe harm to the patient” (my emphasis). Although this may be a result of linguistic imprecision, it indicates the problem with this alternative conception of disease in order to clarify overdiagnosis: it lacks a clear concept of disease.

  6. As will be argued later, the qualifier “malignant changes” presupposes what is to be shown, i.e., that it is a disease.

  7. Walker and Roger also include non-harmful conditions in their conception of diagnosis. In fact they include it even in their definitions of disease, both in “diseaseODx” and in “disease (simpliciter).” Addressing this issue is beyond the scope of this article.

  8. This is what Walker and Rogers call “non-harmful disease,” but, as will be explained below, is not disease at all.

  9. Just to be clear, this does not mean that death always is undesirable.

  10. One of the reasons for this was that experiences, observable phenomena, and altered behaviors and social roles were quite immediate (i.e., late detection).

  11. I owe this argument to one of the reviewers.

  12. I owe this argument to one of the reviewers.

  13. I owe this argument to one of the reviewers.

References

  • Agich, George J. 1983. Disease and value: a rejection of the value-neutrality thesis. Theoretical Medicine 4(1): 27–41.

    Article  Google Scholar 

  • Black, W. C. 1998. Advances in radiology and the real versus apparent effects of early diagnosis. European Journal of Radiology 27(2): 116–122.

    Article  Google Scholar 

  • Black, W. C. 2000. Overdiagnosis: an underrecognized cause of confusion and harm in cancer screening. Journal of the National Cancer Institute 92(16): 1280–1282.

    Article  Google Scholar 

  • Blumenthal-Barby, J. S. 2013. “Choosing wisely” to reduce low-value care: a conceptual and ethical analysis. The Journal of Medicine and Philosophy 38(5): 559–580. doi:10.1093/jmp/jht042.

    Article  Google Scholar 

  • Bolton, Derek. 2008. What is mental disorder?: an essay in philosophy, science, and values. Oxford: Oxford University Press.

    Book  Google Scholar 

  • Boorse, C. 1976. What a theory of mental health should be. Journal for the Theory of Social Behaviour 6: 61–84.

  • Boorse, C. 1977. Health as a theoretical concept. Philosophy of Science 44: 542.

  • Brenner, H., L. Altenhofen, C. Stock, and M. Hoffmeister. 2015. Prevention, early detection, and overdiagnosis of colorectal cancer within 10 years of screening colonoscopy in Germany. Clinical Gastroenterology & Hepatology 13(4): 717–723. doi:10.1016/j.cgh.2014.08.036.

    Article  Google Scholar 

  • Canguilhem, G. 1991. The normal and the pathological. New York: Zone Books.

    Google Scholar 

  • Carter, S. M., W. Rogers, I. Heath, C. Degeling, J. Doust, and A. Barratt. 2015. The challenge of overdiagnosis begins with its definition. BMJ 350: h869. doi:10.1136/bmj.h869.

    Article  Google Scholar 

  • Carter, S. M., C. Degeling, J. Doust, and A. Barratt. 2016a. A definition and ethical evaluation of overdiagnosis. Journal of Medical Ethics. doi:10.1136/medethics-2015-102928.

    Google Scholar 

  • Carter, S. M., J. Doust, C. Degeling, and A. Barratt. 2016b. A definition and ethical evaluation of overdiagnosis: response to commentaries. Journal of Medical Ethics. doi:10.1136/medethics-2016-103822.

    Google Scholar 

  • Christakis, N. A. 1999. Death foretold: prophecy and prognosis in medical care. Chicago: University of Chicago Press.

    Google Scholar 

  • Copeland, D. D. 1977. Concepts of disease and diagnosis. Perspectives in Biology and Medicine 20(4): 528–538.

    Article  Google Scholar 

  • DeVito, S. 2000. On the value-neutrality of the concepts of health and disease: unto the breach again. The Journal of Medicine and Philosophy 25(5): 539–567. doi:10.1076/0360-5310(200010)25:5;1-w;ft539.

    Article  Google Scholar 

  • Ereshefsky, M. 2009. Defining ‘health’ and ‘disease’. Studies in History and Philosophy of Biological and Biomedical Sciences 40(3): 221–227. doi:10.1016/j.shpsc.2009.06.005.

    Article  Google Scholar 

  • Esserman, L. J., I. M. Thompson, Jr., and B. Reid. 2013. Overdiagnosis and overtreatment in cancer: an opportunity for improvement. JAMA: The Journal of the American Medical Association 310(8): 797–798. doi:10.1001/jama.2013.108415.

    Article  Google Scholar 

  • Esserman, Laura J., Ian M. Thompson, Brian Reid, Peter Nelson, David F. Ransohoff, H. Gilbert Welch, and Shelley Hwang et al. 2014. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. The Lancet Oncology 15(6):e234–e242. doi:10.1016/S1470-2045(13)70598-9.

    Article  Google Scholar 

  • Hersch, J., A. Barratt, J. Jansen, L. Irwig, K. McGeechan, G. Jacklyn, H. Thornton, H. Dhillon, N. Houssami, and K. McCaffery. 2015. Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial. Lancet. doi:10.1016/s0140-6736(15)60123-4.

    Google Scholar 

  • Hofmann, B. 2002. Is there a technological imperative in health care? International Journal of Technology Assessment in Health Care 18(3): 675–689.

    Google Scholar 

  • Hofmann, Bjørn. 2014. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. European Journal of Epidemiology 29(9): 599–604. doi:10.1007/s10654-014-9920-5.

    Article  Google Scholar 

  • Hofmann, Bjørn. 2015. Too much technology. BMJ (British Medical Journal). doi:10.1136/bmj.h705.

    Google Scholar 

  • Hofmann, B. 2016a. Conceptual overdiagnosis. A comment on Wendy Rogers and Yishai Mintzker’s article “Getting clearer on overdiagnosis”. Journal of Evaluation in Clinical Practice. doi:10.1111/jep.12652.

    Google Scholar 

  • Hofmann, B. 2016b. Defining and evaluating overdiagnosis. Journal of Medical Ethics 42(11): 715–716.

    Article  Google Scholar 

  • Hofmann, B. 2016c. Medicalization and overdiagnosis: different but alike. Medicine, Health Care, and Philosophy 19(2): 253–264. doi:10.1007/s11019-016-9693-6.

    Article  Google Scholar 

  • Hofmann, Bjørn. 2017. Suffering: harm to bodies, minds, and persons. In Handbook of the philosophy of medicine, eds. Thomas Schramme, and Steven Edwards, 129–145. Dordrecht: Springer Netherlands.

    Chapter  Google Scholar 

  • Khushf, G. 2007. An agenda for future debate on concepts of health and disease. Medicine, Health Care and Philosophy 10(1):19–27. doi:10.1007/s11019-006-9021-7 (discussion 29–32).

    Article  Google Scholar 

  • Kingma, E. 2014. Naturalism about health and disease: adding nuance for progress. The Journal of Medicine and Philosophy 39(6): 590–608. doi:10.1093/jmp/jhu037.

    Article  Google Scholar 

  • Kovacs, J. 1998. The concept of health and disease. Medicine, Health Care, and Philosophy 1(1): 31–39.

    Article  Google Scholar 

  • Marcus, Pamela M, Philip C Prorok, Anthony B Miller, Emily J DeVoto, and Barnett S Kramer. 2015. Conceptualizing overdiagnosis in cancer screening. Journal of the National Cancer Institute 107(4): djv014.

    Article  Google Scholar 

  • Morrison, M. 2016. Overdiagnosis, medicalisation and social justice: commentary on Carter et al (2016) ‘A definition and ethical evaluation of overdiagnosis’. Journal of Medical Ethics. doi:10.1136/medethics-2016-103717.

    Google Scholar 

  • Moynihan, R. N., G. P. Cooke, J. A. Doust, L. Bero, S. Hill, and P. P. Glasziou. 2013. Expanding disease definitions in guidelines and expert panel ties to industry: a cross-sectional study of common conditions in the United States. PLoS Medicine 10(8): e1001500. doi:10.1371/journal.pmed.1001500.

    Article  Google Scholar 

  • Moynihan, R., D. Henry, and K. G. Moons. 2014. Using evidence to combat overdiagnosis and overtreatment: evaluating treatments, tests, and disease definitions in the time of too much. PLoS Medicine 11(7): e1001655. doi:10.1371/journal.pmed.1001655.

    Article  Google Scholar 

  • Parsons, T. 1958. Definitions of health and illness in the light of american values and social structure. In Patients, physicians and illness : sourcebook in behavioral science and medicine, ed. E. G. Jaco, 165–187. New York: Free Press.

    Google Scholar 

  • Rogers, W. 2015. Understanding overdiagnosis as a form of medicalisation. Paper presented at the 29th European conference on philosophy of medicine and health care, Ghent, August 22.

  • Rogers, W. A., and Y. Mintzker. 2016a. Casting the net too wide on overdiagnosis: benefits, burdens and non-harmful disease. Journal of Medical Ethics. doi:10.1136/medethics-2016-103715.

    Google Scholar 

  • Rogers, W. A., and Y. Mintzker. 2016b. Getting clearer on overdiagnosis. Journal of Evaluation in Clinical Practice. doi:10.1111/jep.12556.

    Google Scholar 

  • Sade, R. M. 1995. A theory of health and disease: the objectivist-subjectivist dichotomy. The Journal of Medicine and Philosophy 20(5): 513–525.

    Article  Google Scholar 

  • Sadegh-Zadeh, K. 2000. Fuzzy health, illness, and disease. The Journal of Medicine and Philosophy 25(5): 605–638. doi:10.1076/0360-5310(200010)25:5;1-w;ft605.

    Article  Google Scholar 

  • Sadegh-Zadeh, K. 2008. The prototype resemblance theory of disease. The Journal of Medicine and Philosophy 33(2): 106–139. doi:10.1093/jmp/jhn004.

    Article  Google Scholar 

  • Schwartz, Peter H. 2007. Defining dysfunction: natural selection, design, and drawing a line. Philosophy of Science 74(3): 364–385.

    Article  Google Scholar 

  • Schwartz, Peter H. 2008. Risk and disease. Perspectives in Biology and Medicine 51(3): 320–334.

    Article  Google Scholar 

  • Stempsey, William E. 1999. Disease and diagnosis: value-dependant realism. Dortrecht: Kluwer.

    Google Scholar 

  • Svenaeus, F. 2014. Homo patologicus. Stockholm: Tankekraft.

    Google Scholar 

  • Tranöy, Knut Erik. 1967. Asymmetries in ethics: on the structure of a general theory of ethics. Inquiry: A Journal of Medical Care Organization, Provision and Financing 10(1–4): 351–372.

    Article  Google Scholar 

  • Wakefield, J. C. 2014. The biostatistical theory versus the harmful dysfunction analysis, part 1: is part-dysfunction a sufficient condition for medical disorder? The Journal of Medicine and Philosophy 39(6): 648–682. doi:10.1093/jmp/jhu038.

    Article  Google Scholar 

  • Walker, Mary Jean, and Wendy Rogers. 2016. Defining disease in the context of overdiagnosis. Philosophy of Medicine and Health Care. doi:10.1007/s11019-016-9748-8 (Epub ahead of print).

    Google Scholar 

  • Welch, H. Gilbert, Lisa Schwartz, and Steve Woloshin. 2011. Overdiagnosed: making people sick in the pursuit of health. Boston: Beacon Press.

    Google Scholar 

Download references

Acknowledgements

I am most thankful for wise comments and suggestions by two anonymous reviwers.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Institute for the Health Sciences, The Norwegian University Science and Technology, PO Box 1, 2802, Gjøvik, Norway

    Bjørn Hofmann

  2. Centre for Medical Ethics, The University of Oslo, Oslo, Norway

    Bjørn Hofmann

Authors
  1. Bjørn Hofmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bjørn Hofmann.

Ethics declarations

Conflict of interest

The author declare that he has no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hofmann, B. The overdiagnosis of what? On the relationship between the concepts of overdiagnosis, disease, and diagnosis. Med Health Care and Philos 20, 453–464 (2017). https://doi.org/10.1007/s11019-017-9776-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11019-017-9776-z

Keywords

Search

Navigation