Defining disease in the context of overdiagnosis

Electrochemistry in a Two- or Three-Electrode Configuration to Understand Monopolar or Bipolar Configurations of Platinum Bionic Implants

Electrodes are used in vivo for chemical sensing, electrophysiological recording, and stimulation of tissue. The electrode configuration used in vivo is often optimised for a specific anatomy and biological or clinical outcomes, not electrochemical performance. Electrode materials and geometries are constrained by biostability and biocompatibility issues and may be required to function clinically for decades. We performed benchtop electrochemistry, with changes in reference electrode, smaller counter-electrode sizes, and three- or two-electrode configurations. We detail the effects different electrode configurations have on typical electroanalytical techniques used on implanted electrodes. Changes in reference electrode required correction by application of an offset potential. In a two-electrode configuration with similar working and reference/counter-electrode sizes, the electrochemical response was dictated by the rate-limiting charge transfer step at either electrode. This could invalidate calibration curves, standard analytical methods, and equations, and prevent use of commercial simulation software. We provide methods for determining if an electrode configuration is affecting the in vivo electrochemical response. We recommend sufficient details be provided in experimental sections on electronics, electrode configuration, and their calibration to justify results and discussion. In conclusion, the experimental limitations of performing in vivo electrochemistry may dictate what types of measurements and analyses are possible, such as obtaining relative rather than absolute measurements.

Race, class, caste, disability, sterilisation and hysterectomy

This interdisciplinary historical paper focuses on the past and current state of diverse forms of surgical hysterectomy as a global phenomenon relating to population control and sterilisation. It is a paper grounded in historical inquiry but is unconventional relative to the norms of historical scholarship both in its wide geographical scope informed by the methodologies of global and intercultural history, in its critique of current clinical practices informed by recent feminist, race, biopolitical and disability studies, and by its engagement with scholarship in health sociology and medical anthropology which has focused on questions of gender and healthcare inequalities. The first part of the paper surveys existing medical, social-scientific and humanistic research on the racial, class, disability and caste inequalities which have emerged in the recent global proliferation of hysterectomy; the second part of the paper is about the diverse global rationales underlying radical gynaecological surgeries as a form of sterilisation throughout the long twentieth century. Radical gynaecological surgeries have been promoted for several different purposes throughout their history and, of course, are sometimes therapeutically necessary. However, they have often disproportionately impacted the most disadvantaged groups in several different global societies and have frequently been concentrated in populations that are already maligned on the basis of race, ethnicity, age, criminality, disability, gender deviation, lower class, caste or poverty. This heritage continues to inform current practices and contributes to ongoing global inequalities of healthcare.

Investigating the feasibility and ethical implications of phenotypic screening using stem cell-derived tissue models to detect and manage disease

Stem-cell-derived tissue models generated from sick people are being used to understand human development and disease, drug development, and drug screening. However, it is possible to detect disease phenotypes before a patient displays symptoms, allowing for their use as a disease screening tool. This raises numerous issues, some of which can be addressed using similar approaches from genetic screenings, while others are unique. One issue is the relationship between disease disposition, biomarker detection, and patient symptoms and how tissue models could be used to define disease. Other issues include decisions of when to screen, what diseases to screen for, and what treatment options should be offered.

Health and disease as practical concepts: exploring function in context-specific definitions

Despite the longstanding debate on definitions of health and disease concepts, and the multitude of accounts that have been developed, no consensus has been reached. This is problematic, as the way we define health and disease has far-reaching practical consequences. In recent contributions it is proposed to view health and disease as practical- and plural concepts. Instead of searching for a general definition, it is proposed to stipulate context-specific definitions. However, it is not clear how this should be realized. In this paper, we review recent contributions to the debate, and examine the importance of context-specific definitions. In particular, we explore the usefulness of analyzing the relation between the practical function of a definition and the context it is deployed in. We demonstrate that the variety of functions that health and disease concepts need to serve makes the formulation of monistic definitions not only problematic but also undesirable. We conclude that the analysis of the practical function in relation to the context is key when formulating context-specific definitions for health and disease. At last, we discuss challenges for the pluralist stance and make recommendations for future research.

Ethical Issues of Digital Twins for Personalized Health Care Service: Preliminary Mapping Study

BACKGROUND

The concept of digital twins has great potential for transforming the existing health care system by making it more personalized. As a convergence of health care, artificial intelligence, and information and communication technologies, personalized health care services that are developed under the concept of digital twins raise a myriad of ethical issues. Although some of the ethical issues are known to researchers working on digital health and personalized medicine, currently, there is no comprehensive review that maps the major ethical risks of digital twins for personalized health care services.

OBJECTIVE

This study aims to fill the research gap by identifying the major ethical risks of digital twins for personalized health care services. We first propose a working definition for digital twins for personalized health care services to facilitate future discussions on the ethical issues related to these emerging digital health services. We then develop a process-oriented ethical map to identify the major ethical risks in each of the different data processing phases.

METHODS

We resorted to the literature on eHealth, personalized medicine, precision medicine, and information engineering to identify potential issues and developed a process-oriented ethical map to structure the inquiry in a more systematic way. The ethical map allows us to see how each of the major ethical concerns emerges during the process of transforming raw data into valuable information. Developers of a digital twin for personalized health care service may use this map to identify ethical risks during the development stage in a more systematic way and can proactively address them.

RESULTS

This paper provides a working definition of digital twins for personalized health care services by identifying 3 features that distinguish the new application from other eHealth services. On the basis of the working definition, this paper further layouts 10 major operational problems and the corresponding ethical risks.

CONCLUSIONS

It is challenging to address all the major ethical risks that a digital twin for a personalized health care service might encounter proactively without a conceptual map at hand. The process-oriented ethical map we propose here can assist the developers of digital twins for personalized health care services in analyzing ethical risks in a more systematic manner.

How to Draw the Line Between Health and Disease? Start with Suffering

How can we draw the line between health and disease? This crucial question of demarcation has immense practical implications and has troubled scholars for ages. The question will be addressed in three steps. First, I will present an important contribution by Rogers and Walker who argue forcefully that no line can be drawn between health and disease. However, a closer analysis of their argument reveals that a line-drawing problem for disease-related features does not necessarily imply a line-drawing problem for disease as such. The second step analyzes some alternative approaches to drawing the line between health and disease. While these approaches do not provide full answers to the question, they indicate that the line-drawing question should not be dismissed too hastily. The third step investigates whether the line-drawing problem can find its solution in the concept of suffering. In particular, I investigate whether returning to the origin of medicine, with the primary and ultimate goal of reducing suffering, may provide sources of demarcation between health and disease. In fact, the reason why we pay attention to particular phenomena as characteristics of disease, consider certain processes to be relevant, and specific functions are classified as dys-functions, is that they are related to suffering. Accordingly, using suffering as a criterion of demarcation between health and disease may hinder a wide range of challenges with modern medicine, such as unwarranted expansion of disease, overdiagnosis, overtreatment, and medicalization.

Overdiagnosis: one concept, three perspectives, and a model

Defining, estimating, communicating about, and dealing with overdiagnosis is challenging. One reason for this is because overdiagnosis is a complex phenomenon. In this article we try to show that the complexity can be analysed and addressed in terms of three perspectives, i.e., that of the person, the professional, and the population. Individuals are informed about overdiagnosis based on population-based estimates. These estimates depend on professionals' conceptions and models of disease and diagnostic criteria. These conceptions in turn depend on individuals' experience of suffering, and on population level outcomes from diagnostics and treatment. As the personal, professional, and populational perspectives are not easy to reconcile, we must address them explicitly and facilitate interaction. Population-based estimates of overdiagnosis must be more directly informed by personal need for information. So must disease definitions and diagnostic criteria. Only then can individuals be appropriately informed about overdiagnosis.

Theoretical and clinical disease and the biostatistical theory

Although concepts of disease have received much scrutiny, the benefits of distinguishing between theoretical and clinical disease-and what is meant by those terms-may not be as readily apparent. One way of characterizing the distinction between theoretical and clinical conceptions of disease is by relying on Boorse's biostatistical theory (BST) for a conception of theoretical disease. Clinical disease could then be defined as theoretical disease that is diagnosed. Explicating this distinction provides a useful extension of the BST. The benefits of this approach are clearly and non-normatively demarcating disease from non-disease, while allowing for values and purpose to determine what criteria are used in clinical practice to represent a disease's underlying dysfunction. Through discussion of a variety of medical conditions, including polycystic ovary syndrome and type 2 diabetes mellitus, I explore how the relationship between BST-based theoretical and clinical disease could make sense of various features of clinical practice and medical theory. It could do this by lending focus to a nuanced understanding of the pathophysiological defects present in disease and the means by which they are assessed. This could contribute to making sense of revised nosologies and diagnostic criteria.

Getting personal on overdiagnosis: On defining overdiagnosis from the perspective of the individual person

How can overdiagnosis be defined, explained, and estimated on an individual level? The answers to this question are essential for persons to be able to make informed choices and give valid consents for tests. Traditional conceptions of overdiagnosis tend to depend on counterfactual thinking and prophetic abilities as you would have to know what would happen in the future if you did not test now. To avoid this, overdiagnosis can be defined in terms of the chance of diagnosing a person with a disease when this does not avoid or reduce manifest disease. To be able to relate this to 1's own life and deliberation, I argue that we need answers to specific questions such as the following: If I am tested, and the test and subsequent test results are positive, but I am not treated, what is the chance that I would not experience and suffer from manifest disease? A definition of overdiagnosis that aims at providing answers to this question is as follows: Prospectively overdiagnosis (of an individual person) is given by the estimated chance that a person having a positive test result would not experience and suffer from manifest disease if not treated or followed up in any way. Getting personal on overdiagnosis directs the attention of overdiagnosis estimates towards what matters in medicine: the experience of individual persons.

Précising definitions as a way to combat overdiagnosis

Roughly, overdiagnosis (ODx) occurs when people are harmed by receiving diagnoses (often accompanied by interventions) that do not benefit them, usually because the diagnosed conditions do not pose a threat to their health. ODx is a theoretical as well as a practical problem as it relates to definitions of disease. Elsewhere, it has been argued that disease is a vague concept and that this vagueness may contribute to ODx. In response, we develop a stipulative or précising definition of disease, for the specific purpose of decreasing or preventing ODx. We call this disease_ODx , aimed at distinguishing cases where it would be beneficial to identify (and treat the condition) from those where diagnosis is more likely to harm than benefit. A preliminary definition of disease_ODx is that X is a disease_ODx iff there is dysfunction that has a significant risk of causing severe harm. This paper examines the 3 concepts in this definition, using a naturalistic account of function, a Feinbergian account of comparative harm, and a probabilistic understanding of risk. We then test the utility of this approach using examples of clinical conditions that are currently overdiagnosed.

Tamizaje masivo: una revisión de la literatura sociológica

RESUMEN Se provee una revisión de la literatura sociológica a partir de 79 obras referentes a cribados de cáncer y se excluyeron los cribados genéticos prenatal y neonatal. El tamizaje implica el monitoreo de poblaciones aparentemente sanas para rastrear una determinada condición. El rastreo invirtió la concepción tradicional de comprensión sobre las enfermedades al disminuir los umbrales de definición de enfermedad y rompió con la distinción médica tradicional entre enfermos y sanos. A partir de entonces, la práctica clínica comenzó a buscar enfermedades en personas asintomáticas, y así también modificó los comportamientos de los pacientes, que pasaron a ser responsables del cuidado de sí mismos.

Mistaking the Map for the Territory: What Society Does With Medicine Comment on "Medicalisation and Overdiagnosis: What Society Does to Medicine"

Van Dijk et al describe how society's influence on medicine drives both medicalisation and overdiagnosis, and allege that a major political and ethical concern regarding our increasingly interpreting the world through a biomedical lens is that it serves to individualise and depoliticize social problems. I argue that for medicalisation to serve this purpose, it would have to exclude the possibility of also considering problems in other (social or political) terms; but to think that medical descriptions of the world seek to or are able to do this is to misunderstand the purpose and function of model construction in science in general, and medicine in particular. So, if medicalisation is nonetheless used for the depoliticization described by many critics, we must ask what society does with medicine to give it this exclusive authority. I propose that the problem arises from a tendency to mistake the map for the territory, and think a tool to understand certain aspects of the world gives us the complete picture. To resist this process, I suggest health workers should be more open about the purpose and limitations of medicalisation, and the value of alternative descriptions of different aspects of human experience.