What if defining and treating disease is not, after all, the primary function and mission of psychiatry?
“A physician does not treat a disease; he rather treats a sick [diseased] person.”1
Every so often, I treat myself—wait, I mean, torment myself—by reading discussions of psychiatry that appear on Twitter. Now, sometimes these micro-exchanges serve a useful purpose and are well-suited to an age in which the average person’s attention span is roughly that of a gnat. But more often than not, tweets on controversial issues eventually devolve into ad hominem accusations and insults. Consequently, I avoid this and other social media websites as much as possible. Recently, however—like a moth to the flame—I read a few dozen tweets concerning the meaning of the terms, “disease” and “disorder” in general medicine and psychiatry. To paraphrase that great philosopher, Yogi Berra, it was like déjà vu all over again! Virtually the same debate I had with Thomas Szasz nearly 45 years ago2 was vociferously rehashed in a few dozen tweets.
Now, this is not to deny the theoretical relevance of this debate to psychiatry. Indeed, there are excellent discussions of this topic on the website of my colleague, Awais Aftab, MD.3 Additionally, Mark L. Ruffalo, MSW, DPsa, and I have explored the issues surrounding the term disease in some detail, including several fallacies promoted by psychiatry’s critics.4
But when all the semantic underbrush has been cleared away, we are left, in my view, with 2 inescapable conclusions:
(1) In the storied history of medicine, there has never been a single, universally accepted definition of disease; nor is there broad agreement among physicians or philosophers regarding how disease differs fundamentally from the terms disorder, illness, malady, etc.2,5
(2) In pragmatic terms, the definition of disease versus disorder is one of the least important issues facing general medicine and psychiatry today. (Here are 2 important issues: what are we doing, as a society, for the moaning, disheveled young man lying in the alleyway, tormented by “the Devil’s voice” telling him he should rot in hell? And why is the prison system the largest de facto treatment facility in the US for people with mental illnesses?6)
With respect to the futility of searching for the perfect, essential definition of disease—ie, one that specifies its necessary and sufficient features—please do not take my word for it. Here is what the American Medical Association’s Council on Science and Public Health concluded, after having considered whether obesity is a disease:
“Without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state.”7 (italics added)
But wait: what if defining and treating disease is not, after all, the primary function and mission of psychiatry? What if ours is, fundamentally, a ministering profession, aimed at compassionately caring for certain suffering and incapacitated persons?**
Back to Maimonides
Moshe ben Maimon (called Maimonides, 1138-1204) is arguably the greatest Jewish philosopher of the medieval period, as well as one of the most renowned physicians of his age. The epigram at the beginning of this article is sometimes translated as, “The physician should not treat the disease, but the patient who is suffering from it.”8 Thus, Maimonides was primarily focused not on pathophysiologic processes but on the unique suffering of the patient (the term patient is derived from the Latin, patientem, meaning suffering).
To be clear: Maimonides was intensely interested in the physical, emotional, and environmental causes of disease states, and is widely considered a progenitor of psychosomatic medicine.9 Not incidentally, he is arguably the father of modern-day cognitive-behavioral therapy.10 In addition to his voluminous philosophical works, Maimonides wrote treatises or commentaries on everything from asthma to hemorrhoids to depression.8 But his attitude toward the ethos and practice of medicine was decidedly patient-centered, not disease-centered.
As Dr Ruffalo and I have observed4:
“Very few physicians contemplate their overcrowded waiting room and think to themselves, "Hmmm…I wonder which of these patients has a disease, and which has a syndrome, a disorder, a malady, or an illness?" The physician's chief concern is with determining who is experiencing suffering and incapacity (in varying proportions); identifying a likely cause, whenever possible (it often isn't!); and relieving the patient's misery safely and effectively.”
Philosophers of medicine will doubtless continue to debate the demarcations between disease and disorder, and the criteria required for each. That is fine. But the practice of medicine is firmly anchored in the every-day, clinical imperative of relieving the suffering and incapacity of our patients.
Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of Psychiatric TimesTM (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon.
**I have argued in several venues2,5 that the most consistent and useful “family resemblance” among conditions we call disease is the presence of suffering and incapacity, in varying proportions. This is not an essential definition of disease—only a useful, empirical guide to recognizing its presence. But not all instances of suffering and incapacity are disease states. For example, an individual may be suffering and incapacitated as a captive of terrorists. Some patients we care for are suffering and incapacitated owing to existential, spiritual, social, or even environmental causes. We owe them our time, empathy, and compassion no less than we owe patients with debilitating diseases like schizophrenia.
1. Kottek SS. Toward becoming an accomplished physician: Maimonides versus Galen. Rambam Maimonides Med J. 2011;2(4):e0060.
2. Pies R. On myths and countermyths: more on Szaszian fallacies. Arch Gen Psychiatry. 1979;36(2):139-44.
3. Aftab A. When are we justified in calling mental disorders "brain disorders"? Psychiatry at the Margins. January 6, 2023. Accessed February 13, 2023. https://awaisaftab.substack.com/p/when-are-we-justified-in-calling
4. Ruffalo M, Pies RW. Psychiatric diagnosis 2.0: the myth of the symptom checklist. Psychology Today. June 14, 2020. Accessed February 13, 2023. https://www.psychologytoday.com/us/blog/freud-fluoxetine/202006/psychiatric-diagnosis-20-the-myth-the-symptom-checklist
5. Pies RW. What should count as a mental disorder in DSM-V? Psychiatric Times. April 14, 2009. https://www.psychiatrictimes.com/view/what-should-count-mental-disorder-dsm-v
6. Chang A. 'Insane': America's 3 largest psychiatric facilities are jails. Shots: health news from NPR. April 25, 2018. Accessed February 13, 2023. https://www.npr.org/sections/health-shots/2018/04/25/605666107/insane-americas-3-largest-psychiatric-facilities-are-jails
7. Pittman D. Obesity not a disease, AMA council says. Medpage Today. June 17, 2013. Accessed February 13, 2023. https://www.medpagetoday.com/meetingcoverage/ama/39918
8. Rosner F. The Medical Legacy of Moses Maimonides. Ktav Publishing; 1998:30.
9. Soffer A. Maimonides and psychosomatic medicine. Arch Intern Med. 1986;146(4):653.
10. Pies RW. Maimonides and the origins of cognitive-behavioral therapy. Journal of Cognitive Psychotherapy. 1997;11:21-36.