The Concept of Disease in the Pandemic

Today's post is by Maria Cristina Amoretti and Elisabetta Lalumera. They discuss the concept of disease in the time of COVID-19 which they also write about in a recent article in Theoretical Medicine and Bioethics. This is the first of two blog posts on applied philosophy of science and conceptual analysis in the time of COVID-19.

Maria Cristina Amoretti is Associate Professor at the University of Genoa, Department of Antiquity, Philosophy and History (DAFIST) and Vice-Director of PhilHeaD-Philosophy of Health and Disease Research Center. Elisabetta Lalumera is Assistant Professor at the University of Bologna, Department of Life Quality Studies (QUVI), and member of PhilHeaD.

Amoretti and Lalumera

During the pandemic, medical and non-medical interventions of institutions and governments became central to our lives. Sometimes we felt overwhelmed with worry and anxiety, conditions that do not favour philosophical reflection. In our paper we tried to put worry and anxiety in brackets, and critically engage with the question: What concept of disease is implicit in the interventions that institutions and governments are enforcing during the pandemic?

For doing so, we started with imagining an ideally accurate diagnostic test for COVID-19, with respect to which four classes of people can be identified: people who are positive and symptomatic (PS), positive and asymptomatic (PA), negative (N), and untested (U). Our aim was showing how different philosophical accounts of disease, amongst those discussed in the recent philosophical debate, would better describe the four classes of people. Or, alternatively, which concept of disease is implicit in certain patterns of disease and sickness judgements, like those experienced during the pandemic.

We therefore analyzed different versions of function-requiring and harm-requiring accounts of disease. Of all these, the only disease concept that, unlike the others, allows a positive sickness judgement, not only for the PS group, but also for both the PA and the U groups is the social (risk of) harm account, which equates disease with a condition associated with harm, or increased risk of harm, either to the subject or to someone other than the subject.

We then argued that the concept of disease as social (risk of) harm is the one that can be seen as implicit in many institutional interventions during the COVID-19 pandemic. Many countries have imposed strong lockdowns and quarantines for their whole population in order to suppress or mitigate the outbreak of the virus. Sickness exemptions and benefits were extended, including paid sick leave, tax credits, etc. These privileges also coincided with the imposition of social obligations and of limitations of individual freedom. What is important to our point, however, is that anyone, the U group included, was considered sick and, as an extension, diseased.

Our final point in the paper was that the concept of disease as social (risk) of harm should be adopted in emergency cases only and abandoned when the emergency is over. We gave three reasons for this conceptual revision claim. First, under the social (risk of) harm account, a condition that is harmful or potentially harmful for society is a disease irrespectively of its physiological basis. Therefore, perceived risky social deviances, such as homosexuality and drapetomania, or behavioural proclivities, such as heavy drinking, could come to be regarded as diseases. 

Second, in endorsing the social (risk of) harm account, the subjective and phenomenological aspects of disease would be overshadowed, as asymptomatic people would count as diseased simply because they represent a risk to society. Third, given that the social (risk of) harm account would classify not only the PS group but also the PA and U groups as diseased, the number of diseased people would dramatically increase, creating a problem of overdiagnosis and medicalization.