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3 Med., Health Care & Phil. 1 (2000)

handle is hein.journals/medhcph3 and id is 1 raw text is: LA Medicine, Health Care and Philosophy 3: 1-2, 2000. Editorial Medicine's reality In his latest book, philosopher of science Ian Hacking narrates the life cycle of a disease (Hacking, 1999). This disease originated at the end of the 19th cen- tury in Bordeaux, then it flourished and spread like an epidemic to other parts of Europe. Finally, the dis- ease died away after a psychiatric congress in Nantes, where the condition was conceptually fragmented and dissolved into more distinct states and types. The disease known as 'fugue' (Wandertrieb, automatisme ambulatoire, dromomania) was characterized by the irresistible impulse to aimless wandering, followed by partial amnesia for the events of the journey. Many cases have been described, and many theor- ies advanced. Scientists and physicians engaged in debates about its causation and possible cures. The diagnosis is almost never used today, but the condi- tion still is listed in DSM IV, as 'dissociative fugue'. Although it can be precisely indicated where it was born and where it died, because the disease has discrete geographical and temporal existence, it is difficult to clarify the status of this disorder. Although there are elaborated and detailed case narratives, it is difficult to know whether and how a particular reality is represen- ted. Can we say that this disease is 'discovered', or is it 'invented', or is it perhaps better to say that it 'came into being'? Hacking, also author of a previous book on multiple-personality disorder, points to the social and cultural circumstances that are required for the existence of a disease. He rejects the question whether this condition should be considered a 'real' disease as simplistic. Because of his focus on the circumstances, little is said about the experiences and illness of the afflicted person himself. Nowadays, new diseases continue to appear: jungle syndrome, whiplash, chronic fatigue. In this issue, Dekkers and Van Domburg discuss the example of pseudo-epileptic attack disorder (2000). They criticize the idea that diseases are entities that exist in reality separate from patients. They rather propose the view that diseases are constructed in the circumstances of doctor-patient interaction. In distinction to Hacking, the authors emphasize the subjective experiences of the patients; in fact, they argue how the patient's per- spective contributes to the construction of the disease concept. This view seems to consider reality as the res- ult of concrete activities in scientific and technological practices. Such view is counterintuitive to health care professionals. For them, reality is a pre-existent entity. Disease is not a human construct, but a biological fact. Medical science produces theories and representations of the world of (human) biology. These representa- tions are more or less correct. In the medical context it is important to ascertain whether the suffering of the patient is associated with a 'real' disease. Classifying a condition as a disease implies that the suffering has an explanation, that it can be explained by referring to causation. Successful classification also is related to notions of responsibility and culpability; patients with a disease cannot be blamed for the genesis of their signs and symptoms. In analysing the example, Dekkers and Van Dom- burg attempt to develop an intermediary position regarding concepts of disease. Like many philosoph- ers of medicine, they do not like the extreme positions of essentialism vs constructivism (Wackers, 1994), or taxonomic realism vs taxonomic scepticism (Reznek, 1987). Disease neither is a man-made product nor a natural kind existing in the world independently of us; it is not mere invention but also not mere dis- covery. Although the vocabulary can be misleading (patients producing symptoms and doctors giv- ing the patient's signs and symptoms a name), the intermediary position is not constructivist, but rather phenomenological. It is important to make a distinc- tion between the objective world of scientific analysis where we are confronted with diseased organisms and the subjective world of lived experiences where we are confronted with ill persons. 'Disease' and 'ill- ness' belong to different conceptual realms. But first of all, we seem to be engaged in the life-world of human existence where our experiences and relation- ships have meanings. A posteriori, the meaning-realm of the life-world can be decoded, analysed, classi- fied, and transformed through scientific enquiry. The phenomenological perspective is explained in the con- tribution of Svenaeus (2000). Medicine primarily is a concatenation of meetings between human beings in search of understanding illness and suffering. The

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