Back to Basics: Overdiagnosis Is About Unwarranted Diagnosis

Diagnostic staging and stratification in psychiatry and oncology: clarifying their conceptual, epistemological and ethical implications

Staging and stratification are two diagnostic approaches that have introduced a more dynamic outlook on the development of diseases, thus participating in blurring the line between the normal and the pathological. First, diagnostic staging, aiming to capture how diseases evolve in time and/or space through identifiable and gradually more severe stages, may be said to lean on an underlying assumption of "temporal determinism". Stratification, on the other hand, allows for the identification of various prognostic or predictive subgroups based on specific markers, relying on a more "mechanistic" or "statistical" form of determinism. There are two medical fields in which these developments have played a significant role and have given rise to sometimes profound nosological transformations: oncology and psychiatry. Drawing on examples from these two fields, this paper aims to provide much needed conceptual clarifications on both staging and stratification in order to outline how several epistemological and ethical issues may, in turn, arise. We argue that diagnostic staging ought to be detached from the assumption of temporal determinism, though it should still play an essential role in adapting interventions to stage. In doing so, it would help counterbalance stratification's own epistemological and ethical shortcomings. In this sense, the reflections and propositions developed in psychiatry can offer invaluable insights regarding how adopting a more transdiagnostic and cross-cutting perspective on temporality and disease dynamics may help combine both staging and stratification in clinical practice.

Normal isn't normal: On the medicalization of health

BACKGROUND

This study investigated the proportion of the U.S. population classified as healthy based on 10 common indicators, examined in two ways: (1) above or below (in the healthy direction) the sample median (termed "normal"), and (2) below diagnostic cut-off points for clinical caseness or high risk (termed "ideal").

METHODS

Data are from the 2017-March 2020 round of the National Health and Nutrition Examination Survey (NHANES). Sample sizes ranged from 3,956 to 8,961 for respective health indicators, with a total of 3,102 respondents for two weighted multi-item measures described below. Measures included the Alameda 5 health behaviors (smoking, drinking exercising, sleeping, and body mass index) and five standard biomarkers (systolic and diastolic blood pressure, resting heart rate, fasting glucose, and total cholesterol). Besides point prevalences for the normal and ideal categories for each indicator, we also calculated the proportion healthy for all 10 indicators, again calculated both ways, termed "meta-normal" and "meta-ideal."

RESULTS

The prevalence of meta-normality was 1.05%, suggesting that hardly any adult Americans are completely healthy according to population norms. Findings for meta-ideality showed that while most Americans are not clinical cases for any respective indicator, only 5.55% met the official criteria for being healthy according to all 10 indicators.

CONCLUSION

Most Americans appear healthy according to nearly all key health indicators and biomarkers, according to "normal" or "ideal" criteria. However, the proportion healthy according to all measures is extremely small. Relatively few U.S. adults are completely healthy according to clinical criteria (meta-ideal), and even fewer are completely healthy according to population norms (meta-normal). Results are interpreted through sociological writing on medicalization.

Clinical decision making of post-treatment disease

Root-filled teeth presenting with signs of post-treatment disease is a common finding in virtually every dental practice. There is both empirical and experimental evidence that, as long as the condition is asymptomatic, it is often left untreated. Professional judgements and decision making in endodontics as in any medical discipline are based on qualified estimations of the probability and the value of relevant outcomes. In this paper we describe various aspects of clinical decision making in general, from a descriptive as well as a normative point of view, but with a particular focus on the condition of the root-filled tooth with post-treatment disease. We review how attention to various types of uncertainties are relevant for the decision-making process. Additionally, we discuss the nature of value judgements and different concepts of health and disease which are important for understanding the complexity of the clinical decision-making process. We also refer to a set of principal rules that can guide the clinician's decision making in every-day practice in front of a case with endodontic post-treatment disease. Finally, we provide some aspects on the sometime cumbersome decision whether to go for a non-surgical or surgical method, whenever a decision on retreatment has been made.

On the Ethics of Withholding and Withdrawing Unwarranted Diagnoses

The number of diagnoses and the number of persons having diagnoses have increased substantially, and studies indicate that diagnoses are given or upheld even if they are unwarranted, that is, that they do not satisfy professionally accepted diagnostic criteria. In this article, the authors investigate the ethics of withholding and withdrawing unwarranted diagnoses. First, they investigate ethical aspects that make it difficult to withhold and to withdraw such diagnoses. Second, they scrutinize whether there are psychological factors, both in persons/patients and healthcare professionals, making it difficult to withdraw and withhold unwarranted diagnoses. Lastly, they use recent elements of the withholding-versus-withdrawing treatment debate in medical ethics to investigate whether there are any differences between withholding and withdrawing treatment and withdrawing and withholding unwarranted diagnoses. The authors conclude that it is crucial to acknowledge and address all these issues to reduce and avoid unwarranted diagnoses.

Managing the moral expansion of medicine

Science and technology have vastly expanded the realm of medicine. The numbers of and knowledge about diseases has greatly increased, and we can help more people in many more ways than ever before. At the same time, the extensive expansion has also augmented harms, professional responsibility, and ethical concerns. While these challenges have been studied from a wide range of perspectives, the problems prevail. This article adds value to previous analyses by identifying how the moral imperative of medicine has expanded in three ways: (1) from targeting experienced phenomena, such as pain and suffering, to non-experienced phenomena (paraclinical signs and indicators); (2) from addressing present pain to potential future suffering; and (3) from reducing negative wellbeing (pain and suffering) to promoting positive wellbeing. These expansions create and aggravate problems in medicine: medicalization, overdiagnosis, overtreatment, risk aversion, stigmatization, and healthism. Moreover, they threaten to infringe ethical principles, to distract attention and responsibility from other competent agents and institutions, to enhance the power and responsibility of professionals, and to change the professional-beneficiary relationship. In order to find ways to manage the moral expansion of medicine, four traditional ways of setting limits are analyzed and dismissed. However, basic asymmetries in ethics suggest that it is more justified to address people's negative wellbeing (pain and suffering) than their positive wellbeing. Moreover, differences in epistemology, indicate that it is less uncertain to address present pain and suffering than future wellbeing and happiness. Based on these insights the article concludes that the moral imperative of medicine has a gradient from pain and suffering to wellbeing and happiness, and from the present to the future. Hence, in general present pain and suffering have normative priority over future positive wellbeing.

Too Much, Too Mild, Too Early: Diagnosing the Excessive Expansion of Diagnoses

Tremendous scientific and technological advances have vastly improved diagnostics. At the same time, false alarms, overdiagnosis, medicalization, and overdetection have emerged as pervasive challenges undermining the quality of healthcare and sustainable clinical practice. Despite much attention, there is no clarity on the classification and handling of excessive diagnoses. This article identifies three basic types of excessive diagnosing: too much, too mild, and too early. Correspondingly, it suggests three ways to reduce excess and advance high value care: we must stop diagnosing new phenomena, mild conditions, and early signs that do not give pain, dysfunction, and suffering.

On the person in personal health responsibility

In this paper, we start by comparing the two agents, Ann and Bob, who are involved in two car crashes. Whereas Ann crashes her car through no fault of her own, Bob crashes as a result of reckless driving. Unlike Ann, Bob is held criminally responsible, and the insurance company refuses to cover the car's damages. Nonetheless, Ann and Bob both receive emergency hospital treatment that a third party covers, regardless of any assessment of personal responsibility. What warrants such apparent exceptionalism with respect to personal responsibility in the healthcare context? We turn our attention to an understudied aspect of the debate on personal health responsibility, namely, the conceptualisation of the person in need of emergency hospital treatment. Drawing on the research of Joshua Knobe and Shaun Nichols, we propose that a context-dependent conceptualisation of the person may help explain a reluctance to ascribe responsibility to the individual for negative health outcomes.

Acknowledging and addressing the many ethical aspects of disease

Diseases change the life of individuals, the social status of groups, the obligations of professionals, and the welfare of nations. Disease classifications function as a demarcation of access to care, rights, and duties. Disease also fosters social stigmatization and discrimination, and is a personal, professional, and political matter. It raises a wide range of ethical issues that are of utmost importance in patient communication and education. Accordingly, the objective of this article is to present and discuss a range of basic ethical aspects of this core concept of medicine and health care. First and foremost, disease evokes compassion for the person suffering and induces a moral impetus to health professionals and health policy makers to avoid, eliminate or ameliorate disease. The concept of disease has many moral functions, especially with respect to attributing rights and obligations. Classifying something as disease also has implications for the status and prestige of the condition as well as for the attitudes and behavior towards people with the condition. Acknowledging such effects is crucial for avoiding discrimination and good communication. Moreover, different perspectives on disease can create conflicts between patients, professionals and policy makers. While expanding the concept of disease makes it possible to treat many more people for more conditions - earlier, it also poses ethical challenges of doing more harm than good, e.g., in overdiagnosis, overtreatment, and medicalization. Understanding these ethical issues can be difficult even for health professionals, and communicating them to patients is challenging, but crucial for making informed consent. Accordingly, acknowledging and addressing the many specific ethical aspects of disease is crucial for patient communication and education.

Dediagnosing - a novel framework for making people less ill

Diagnosing constitutes a substantial part of healthcare work and triggers a wide range of actions including the prescription of medicines. Dediagnosing is proposed as a novel framework for removing diagnoses that do not contribute to the reduction of persons' suffering and should be introduced to make people less ill. Dediagnosing comes together with other efforts to reduce overuse, such as deimplementation, deprescribing, decommissioning, and disinvestment. Because diagnoses may influence identity construction and social rights, dediagnosing must be conducted in close collaboration with the patient.

Vagueness in Medicine: On Disciplinary Indistinctness, Fuzzy Phenomena, Vague Concepts, Uncertain Knowledge, and Fact-Value-Interaction

This article investigates five kinds of vagueness in medicine: disciplinary, ontological, conceptual, epistemic, and vagueness with respect to descriptive-prescriptive connections. First, medicine is a discipline with unclear borders, as it builds on a wide range of other disciplines and subjects. Second, medicine deals with many indistinct phenomena resulting in borderline cases. Third, medicine uses a variety of vague concepts, making it unclear which situations, conditions, and processes that fall under them. Fourth, medicine is based on and produces uncertain knowledge and evidence. Fifth, vagueness emerges in medicine as a result of a wide range of fact-value-interactions. The various kinds of vagueness in medicine can explain many of the basic challenges of modern medicine, such as overdiagnosis, underdiagnosis, and medicalization. Even more, it illustrates how complex and challenging the field of medicine is, but also how important contributions from the philosophy can be for the practice of medicine. By clarifying and, where possible, reducing or limiting vagueness, philosophy can help improving care. Reducing the various types of vagueness can improve clinical decision-making, informing individuals, and health policy making.

The role of philosophy and ethics at the edges of medicine

BACKGROUND

The edge metaphor is ubiquitous in describing the present situation in the world, and nowhere is this as clearly visible as in medicine. "The edge of medicine" has become the title of books, scholarly articles, media headlines, and lecture series and seems to be imbued with hype, hope, and aversion. In order better to understand what is at stake at "the edge of medicine" this article addresses three questions: What does "the edge of medicine" mean in contemporary debates on modern medicine? What are the challenges "on the edge of medicine" (in these various meanings of "on the edge")? How can philosophy and ethics contribute with addressing these challenges?

METHODS

Literature searches in PubMed and Google Scholar are used to identify uses of the phrase "the edge of medicine" while conventional content analysis is used to analyze meanings of and challenges with "the edge of medicine." These results are then investigated with respect to how philosophy and ethics can address the identified challenges.

RESULTS

The literature reveals that "the edge of medicine" has many meanings, such as: Border; Margin (of life); Frontier; Forefront; Fringes; Plunge (abyss); Brink (verge); Conflict; and Balancing. In general, the various meanings address four basic challenges: setting limits, keeping control, make meaning, and handling conflicts or aporias. The analysis of each of the meanings of "the edge of medicine" identifies a wide range of important and urgent tasks for the humanities in general, and for philosophy and ethics in particular: 1) clarifying concepts; 2) clarifying assumptions and premises of arguments, methods, advice, and decisions; 3) elaborate new concepts and new theories; 4) conceptualize and handle uncertainty, moral regret, and residue; 5) reveal "the emperor's new clothes;" 6) identify trends and reflect on their implications; 7) demarcation; and 8) reflecting on goodness in medicine.

CONCLUSION

The phrase "the edge of medicine" expresses a wide range of challenges for modern health care. Together with other disciplines philosophy and ethics can and should make crucial contributions at "the edge of medicine," which is where the future of human beings and societies is created and formed.

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.

Nipping Diseases in the Bud? Ethical and Social Considerations of the Concept of 'Disease Interception'

‘Disease interception’ describes the treatment of a disease in its clinically inapparent phase and is increasingly used in medical literature. However, no precise definition, much less an ethical evaluation, has been developed yet. This article starts with a definition of ‘disease interception’ by distinguishing it from other preventions. It then analyses the ethical and social implications of the concept in light of the four principles of medical ethics by Beauchamp and Childress. The term ‘disease interception’ refers to a form of secondary prevention applied in a short interception window intended to prevent a preclinical disease from developing further. We propose the definition ‘early and targeted secondary prevention by treatment’. The ethical evaluation of the concept shows that while it promises to be beneficial, it raises a number of ethical and social challenges regarding patient autonomy and justice. In order to ensure decision-making that respects patient autonomy, commercially motivated metaphors such as ‘disease interception’ should make way for precise definitions. Future research should not only focus on how to detect clinically inapparent diseases but also on the ethical question, when this is justifiable and what consequences it has for the individual and society as a whole.

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.

Early detection of type 2 diabetes in socioeconomically disadvantaged areas in Stockholm - comparing reach of community and facility-based screening

BACKGROUND

Type 2 diabetes and its high-risk stage, prediabetes, are often undiagnosed. Early detection of these conditions is of importance to avoid organ complications due to the metabolic disturbances associated with diabetes. Diabetes screening can detect persons unaware of diabetes risk and the elevated glucose levels can potentially be reversed through lifestyle modification and medication. There are mainly two approaches to diabetes screening: opportunistic facility-based screening at health facilities and community screening.

OBJECTIVE

To determine the difference in population reach and participant characteristics between community- and facility-based screening for detection of type 2 diabetes and persons at high risk of developing diabetes.

METHODS

Finnish diabetes risk score (FINDRISC) is a risk assessment tool used by two diabetes projects to conduct community- and facility-based screenings in disadvantaged suburbs of Stockholm. In this study, descriptive and limited inferential statistics were carried out analyzing data from 2,564 FINDRISC forms from four study areas. Community- and facility-based screening was compared in terms of participant characteristics and with population data from the respective areas to determine their reach.

RESULTS

Our study found that persons born in Africa and Asia were reached through community screening to a higher extent than with facility-based screening, while persons born in Sweden and other European countries were reached more often by facility-based screening. Also, younger persons were reached more frequently through community screening compared with facility-based screening. Both types of screening reached more women than men.

CONCLUSION

Community-based screening and facility-based screening were complementary methods in reaching different population groups at high risk of developing type 2 diabetes. Community screening in particular reached more hard-to-reach groups with unfavorable risk profiles, making it a critical strategy for T2D prevention. More men should be recruited to intervention studies and screening initiatives to achieve a gender balance.

An analytic framework for conceptualisations of disease: nine structuring questions and how some conceptualisations of Alzheimer's disease can lead to 'diseasisation'

According to the US National Institute on Aging and the Alzheimer's Association (NIA-AA), Alzheimer's disease (AD) should be understood as a biological construct. It can be diagnosed based on AD-characteristic biomarkers only, even if AD biomarkers can be present many years before a person experiences any symptoms of AD. The NIA-AA's conceptualisation of AD radically challenges past AD conceptualisations. This article offers an analytic framework for the clarification and analysis of meanings and effects of conceptualisations of diseases such as that of AD. This framework consists of nine questions that allows us to determine how the conceptualisations of diseases, such as that of AD, link or decouple the following terms to/from each other: screening, diagnosis, pathology, disease (along the lines of what have been labelled as "biological-physiological" or "normative" conceptions of disease in philosophy of medicine), symptoms, and illness. It also includes questions regarding how specific decouplings open up for new categories through which people can understand themselves in new ways, and what spaces of possibilities specific conceptualisations (and their decouplings and linkages) open to. The article shows how specific decouplings/linkages can open up not only for the phenomena of pathologisation but also for a distinct, but related phenomenon here termed as diseasisation.

Invited Commentary: Beyond Overdiagnosis-Diagnosis Without Benefit

In an accompanying article, Hofmann (Am J Epidemiol. 2019;188(10):1812-1817) seeks to clarify the concept of overdiagnosis by screening. He makes a helpful suggestion to reconnect diagnosis with patient suffering, pointing out the underlying issue in overdiagnosis of prognostic uncertainty. He then divides prognostic uncertainty into developmental and progression uncertainty, using a categorical model of disease progression through indicators to manifest disease. This model could be improved by considering the heterogeneity of patient-condition combinations. This leads to an understanding of the probabilistic nature of the connection between any indicator in a specific individual and patient suffering. The model also needs to consider the time span over which the patient-condition combination leads to patient suffering. I propose a simpler approach that goes further to focus not only on overdiagnosis but also on the broader problem of diagnosis without benefit and diagnosis without net benefit. This makes measurement easier and focuses attention where it belongs: on the harm caused by overly aggressive screening programs.