Three types of expansions, their problems, and potential solutions
Expanding disease beyond pain and suffering
The first expansion of medicine’s moral imperative has been through the extension of the phenomena that medicine is targeting: from experienced phenomena, such as pain and suffering, to non-experienced phenomena, such as paraclinical signs and indicators. This has mainly happened by a vast expansion of the phenomena that fall under the concept of disease (and therefore are considered to be bad). From John Graunt’s Bills of Mortality in 1665 till ICD-11 [2], DSM [29], ICPC [30], and in ICF [31] more people are diagnosed with ever more diseases. Figure 1 shows the expansion of number of disease categories and codes from ICD-1 in 1900 till ICD-11 in 2018.
The expansion in number of disease categories and codes from ICD-1 in 1900 till ICD-11 in 2018. Expanded from [32].
Part of this expansion is because we know more about bodily and mental mechanisms than ever before. By differentiating existing diseases in more precise and actionable entities, more people can be helped—better and earlier than ever before.
However, our causal and predictive powers are (still) less developed than our identifying skills. We tend to infer from discovering conditions to the imperative of handling them [16, 33]. We can detect many more precursors of disease than ever before [34], but we still lack knowledge of whether they will develop into what is morally relevant [27]. Hence, we appear to be better at detecting than at predicting [32]. This results in expanded disease labelling (and potential anxiety), unnecessary subsequent diagnostics and treatment, i.e., overuse of health care services [35, 36].
To a large extent medicine has expanded its subject matter from manifest disease to indicators, for example by labelling indolent conditions as disease [5] or labelling predictors or precursors “disease,” such as pre-diabetes and pre-Alzheimer. Moreover, risk factors, such as hypertension and obesity have been classified as disease [37,38,39,40,41,42]. Additionally, species-typical characteristics, such as menopause and aging, are made disease [43]. The process where preclinical non-symptomatic conditions are understood to be diseases has been called diseasisation [44].
Common to the expansion of disease by including indicators, predictors, precursors, and risk factors into our conceptions of disease is that they can result in overdiagnosis and overtreatment [45], health anxiety, and that we may do more harm than good [46, 47].
However, the expansion of the moral imperative of medicine through the expansion of the concept of disease (as something bad) can be seen in other fields as well. For example, many aesthetic phenomena and non-harmful conditions, such as protruding ears and funnel chest (pectus excavatum) have been classified and handled as diseases even in cases where there is no functional reduction (in hearing or breathing). While socially helpful, it is not clear that doing so reduces pain and suffering in individuals or in society at large [48].
Medicine has also been heavily criticized for including ordinary life experiences and social phenomena in its subject matter, i.e., for medicalization [9, 28, 49]. Grief [50, 51], sexual orientation [52, 53] or identity [54, 55], social behavior (ADHD) [56], and love [57] are but a few examples. While medicalization certainly can be positive [58, 59], it can also divert responsibility from other actors and institutions that may be better at handling these phenomena. For example, families and social networks may sometimes be better at handling grief than health care.
Another important development is that classification systems have been expanded to include health-related issues, not considered to be disease. The reason for this is mainly pragmatic, as classified conditions give rights to attention and care. For some conditions (such as obesity) organizations explicitly state that they do not consider their condition to be disease but in order to obtain access to health services, they insist that it should be classified as a disease [60, 61].
Another pragmatic expansion of disease is when a condition is made disease because it can be detected and treated [62]. Erectile dysfunction (due to the discovery of sildenafil) is but one example. This relates to disease mongering, i.e., making biological or social conditions disease in order to sell diagnostic tests or therapies. Low testosterone (Low T) is one example of this [63, 64]. The problems with this are manifold: healthy persons are made patients, it results in anxiety, overtreatment, or negative side-effects.
The various types of expansion of the concept of disease that contribute to the expansion of medicine’s moral imperative are summarized in Table 1. The main challenges with this type of expansion of the moral imperative of medicine are potential harm from unnecessary diagnostics or treatment, overdiagnosis, overtreatment [5, 65], stigmatization, health anxiety, medicalization, and low-quality and low-value care [13, 14, 66]. Moreover, the allocation of resources for persons without pain and suffering raises concern about equity and justice (opportunity costs with respect to those who are in pain and are suffering). Moreover, the increased involvement with ever larger parts of people’s lives raises concern of professional power and responsibility, as well as professional integrity. Additionally, it changes the professional-beneficiary relationship, as health professionals approach people who do not know that they need help instead of people calling on professionals for help.
Each of these ethical challenges warrant specific analysis. Here the point is that medicine has expanded what falls under the concept (and classification) of disease, and thus counts as the subject matter for the moral imperative of medicine. It has done so by addressing phenomena that cannot be directly related to people’s experience of pain and suffering. This expansion of the moral imperative of medicine to a wide range of phenomena that are not closely linked to experienced pain and suffering may become ever more pertinent in the future when an unprecedented number of new biomarkers, risk factors, social issues, and indicators emerge from the convergence of omics, Big Data, Artificial Intelligence, precision medicine [67], and enormous investments [68].
Hence, when expanding the moral imperative to phenomena and conditions that can be closely connected to people’s experiences, such as pain and suffering, the expansion is warranted. However, when targeting conditions that will not result in pain and suffering (overdiagnosis), where the pain or suffering is an ordinary-life experience or socially constructed (medicalization), or where making something a disease will increase stigmatization, medicine makes a problematic moral expansion that raises profound ethical concerns as it does more harm than good.
From present to future pain and suffering
The second expansion of the moral imperative has been to extend medicine’s concern for reducing negative wellbeing from the present to the future: from alleviating current pain and suffering to avoiding this in the future. While preventive medicine measures are directed towards the traditional target of medicine’s moral imperative, i.e., the phenomena of pain and suffering, they tend to target healthy people to avoid such phenomena in the future. The idiom “an ounce of prevention is worth a pound of cure” expresses well the rationale behind this expansion.
While it has been argued that preventive measures are tasks beyond the scope of medicine [28, 71], in practice it is clearly one of its integrated and time consuming tasks [72]. Moreover, while some preventive measures are effective in avoiding and reducing pain and suffering, other measures, such as screening and health checks, are shown to be less effective than presumed [73,74,75,76,77]. Other institutions than the health services may be more important for preventing disease. Alzheimer disease may serve as one example, where non-medical factors are pivotal for prevention [78].
Additionally, providing health services to presently healthy persons to avoid potentially future pain at the expenses of attention to persons with present pain and suffering, poses challenges in priority setting [79, 80]. Correspondingly, medicine has been criticized for exercising power over people’s private and ordinary life by various preventive measures and for changing the professional-patient relationship [81]. Introducing and enhancing health anxiety, risk aversion, orthorexia [82] and promoting healthism (elevating health to a super value) [28] have been shown to reduce the benefits of preventive measures.
In sum, expanding from present to future harm and suffering can do more harm than good, distract from other more appropriate measures, challenge justice, displace power and responsibility, and challenge the patient-professional relationship. This does of course not rule out preventive measures, which are clearly warranted, for example when they in fact obstruct future pain and suffering without opportunity costs for presently suffering persons that could be helped. However, and adding to the problem, we do not always know that the positive future effects will occur and will outweigh present and future negative effects. See below.
Figure 2 illustrates the dilemma of balancing present and future harms and benefits with curative versus preventive measures. For curative measures the benefits and the harms often appear at the same time. For preventive measures, the benefits may occur in the future, while the harms can occur at present.
Comparing harms and benefits in curative and preventive measures
Hence, the very reasonable temporal moral expansion from present to future pain and suffering has some important premises and potential negative effects. Accordingly, we need to address these issues in order to ascertain the benefits of preventive medicine and avoiding its harms.
From alleviating pain to promoting pleasure
The third moral expansion of medicine has been to extend its imperative from addressing negative wellbeing to positive wellbeing, e.g., from pain to pleasure. In line with WHO’s definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [83], positive wellbeing has been promoted as the goal of medicine and health policy [84]. No doubt, medicine has obtained great success as “the greatest benefit to mankind ”[18]. Moreover, its recipe for improving the conditions for humans has inspired a range of other fields, such as social care. Accordingly, the normative goal of medicine has expanded beyond the traditional end to alleviate and avoid pain and suffering. It has become to increase the positive wellbeing of human beings [85]. This may be strived for in many ways, e.g., by paying attention to the social determinants of health [86], by “improving” appearance, such as in cosmetic plastic surgery; by enhancing human characteristics, such as resilience, physical strength, sexual performance, gender identity, self-confidence [87], intelligence, emotional stability, longevity, moral capacity [88], love [57], and happiness [89]; or by fulfilling people’s wishes [90].
Certainly, to pay attention to positive wellbeing (as well as happiness and determinants of health) is crucial, but this may also come with some problems. For example, the expansion of wellbeing can absolve other institutions and politicians from their responsibilities for peoples’ positive wellbeing, i.e., it can become a moral distraction [3]. Moreover, emerging biotechnologies, such as personalized medicine, gene editing, and artificial intelligence, may be forceful tools to promote human positive wellbeing. However, given limited resources, it is contested whether positive wellbeing (e.g., happiness) should be the primary goal of medicine [85, 91, 92]. As there still are so many individuals with pain and suffering that can be addressed by healthcare, it can infringe the principle of justice to promote the positive wellbeing of a selected group of persons who are considered to be healthy.
Correspondingly, the expansion from alleviating pain to promoting pleasure also raises concerns for non-maleficence and beneficence as the consequences of promoting positive wellbeing are difficult to predict and measure and can be harmful [93]. As alluded to, making medicine the master of positive wellbeing may give it power over areas that are otherwise considered to belong to the realm of politics. When health professionals do not only help people with their pain and suffering, but are accountable for their wellbeing and happiness, it alters the professional-beneficiary relationship. The point here is not to dismiss medicine’s potential role in improving positive wellbeing but only to point out that this expansion raises specific moral concerns.
Hence, the expansion in the moral imperative from reducing negative wellbeing to promoting positive wellbeing raises concern for harm, beneficence, distraction, justice, power and responsibility, integrity, as well as altered relationship between professionals and beneficiaries. Figure 3 illustrates the moral expansion from pain to pleasure (expansion of wellbeing) and from present/past to future pain (temporal expansion).
Moral expansion from pain to pleasure and from present/past to future
Managing moral expansions
So far, I have identified three types of expansions of the moral imperative in medicine: (1) by including a wide range of non-experienced phenomena beyond experienced pain and suffering; (2) including future benefits in addition to present harms; and (3) targeting people’s positive wellbeing. I have also pointed out potential problems with these expansions, such as overdiagnosis, overtreatment, medicalization, stigmatization, risk aversion, health anxiety, and healthism. Moreover, such implications can infringe basic ethical principles, such as non-maleficence, beneficence, and justice, and, to the extent that people are not informed, also autonomy. They can distract attention and responsibility from other competent agents (such as politicians), enhance the power and responsibility of professionals, and change the professional-beneficiary relationship.
These findings urge the question of how to address the moral expansions of the moral imperative of medicine. Let me briefly address the question along four traditional lines of thought: Aligning medicine with its (a) basic concepts, (b) ethos, (c) basic goals, and (d) with conceptions of making medicine better.
Aligning medicine with its basic concepts
The first approach to manage the expansion of the moral imperative of medicine would be to use key concepts in medical tradition, such as disease, therapy, and naturalness, as its normative measure. According to such approaches, medicine should stick to the treatment of disease (and abstain from enhancement of health) in order to (re-)establish natural human functioning (and abstain from improvement). However, naturalness can mean many things [94,95,96] and reference to nature may not provide robust normative guidance [97, 98]. The same problem occurs when we try to use the therapy-enhancement distinction to restrict the moral expansion of medicine. Vaccines are good counterexamples reducing the usefulness of this distinction, which has been shown to be blurred and not very action-guiding [97, 98].
Referring to the distinction between health and disease does not do any heavy lifting either, as the moral expansion undermines this traditional distinction [99]. As demonstrated above, the concept of disease is under continuous expansion. Moreover, it has been argued that concepts like health and disease are vague [100,101,102,103], fuzzy [104, 105], unnecessary [106, 107], or essentially contested concepts [108]. Hence, the basic concepts in medicine do not seem to do the job.
Aligning medicine with its ethos
Another approach to harness or manage the moral expansion of medicine could be to refer to the ethos of medicine, which has been defined as its “essential operative values”[109]. Accordingly, any moral expansion of medicine beyond its ethos is not warranted [110, 111]. However, the norms and values of medicine are diverse and changing. Moreover, there is no agreement on a consistent definition of ethos [109, 112,113,114], and referring to specific definitions of the ethos of medicine may not solve the problem either. For example, the ethos of medicine has been defined as “the normative social structure, moral shape or order” of a particular field (medicine) [110]. As the “moral shape or order” is exactly what is changing in the moral expansion described above, referring to the ethos of medicine does not seem very helpful for managing the moral expansion.
Aligning medicine with its basic goals
Yet another approach to control and direct the moral expansion is to assure that medicine is aligned with its goals. In their seminal work, Hanson and Callahan listed four basic goals of medicine: (1) prevention of disease and promotion of health, (2) relief of suffering (caused by malady), (3) care of the ill, and (4) avoidance of premature death [115]. However, there has been a substantial and extensive debate on what are the appropriate goals of medicine without culminating in consensus [115,116,117,118,119,120,121,122,123,124,125,126,127,128]. Additionally, there are many interpretations of each goal. For example, many of the examples of harmful expansion above are developed in accordance with the goals stated by Hanson and Callahan and colleagues. Biomarker testing and cancer screening resulting in overdiagnosis and overtreatment are but two examples. Moreover, new goals that expand the moral imperative of medicine have been suggested. For example, various kinds of welfarist goals of medicine [129,130,131] tend to augment rather than to control the moral expansion. The same problem occurs for attempts to define the “nature of medicine” [126, 132, 133], “the essence of medicine” [134], or “the end of medicine” (being different from the goal) [132]. Addressing all such approaches is beyond the scope of this article. The point here is rather that such teleological approaches may not have the norm-regulating impact that is required.
While acknowledging the difficulties with restricting or directing the expansion of the moral imperative of medicine as described above, there still seem to be some relevant options related to the concept of goodness.
Making medicine better
We can ask whether the moral expansion makes medicine better. In cases of overdiagnosis, overtreatment, stigmatization, and the creation of health anxiety the answer is no. However, the three types of moral expansions identified do not only have bad implications. They can certainly be helpful and even lifesaving, for example when avoiding a mortal disease by an identifying biomarker. The problem is to differentiate the good from the bad. It is partly a prognostic and predictive problem (see below) and partly a problem of knowing what we mean by better. If we can ascertain that a specific kind of moral expansion makes the life of patients or persons better, it should certainly be endorsed. However, as we have learned from the enhancement debate, which partly has confused quantity (more functioning) with quality (better life), it is not clear what makes the life of patients and persons better [97]. As there are many conceptions of the goals and values of medicine, there are many conceptions of what is better in medicine [128].
This indicates that the traditional ways of addressing moral issues in medicine (aligning medicine with its basic concepts, with its ethos, with its basic goals, and with conceptions of making medicine better) may not work for addressing the expansion of the moral imperative in medicine. Does this mean that there are no resources for managing the expansion of the moral imperative of medicine? Before concluding pessimistically on this question, let us briefly examine two crucial issues: differences in uncertainty and in moral imperative.
Epistemic differences
Medicine is inevitably an uncertain endeavor. Diagnoses are inaccurate, prognoses are unreliable, and predictions and the outcomes of treatments are uncertain [135]. As already pointed out, our predictive powers are (still) less developed than our detecting skills. We are good at identifying indicators, but not so good at knowing whether they matter [136].
While uncertainty is existing both in present and with respect to the future, we know in general less about the future than about the present. Prognostic (and predictive) uncertainty adds to present uncertainty [27]. Hence, our understanding of good and bad here and now appears in general to be less uncertain than that in the future. Accordingly, it can be argued that overall present events have an epistemic advantage over future events, and that we should prioritize to promote good and avoid bad here and now compared to in the future. This is, however, not to say that a present uncertain good should have priority over a future uncertain good. The basic principle is epistemic, and not temporal.
Therefore, from an epistemic point of view (in cases where future events and outcomes are more uncertain than present events and outcomes) it can be argued that we should give priority to present events and outcomes. Such an argument could be made from the principle of beneficence (what is best for persons), from the perspective of maximizing utility (utilitarianism), from the duty to help individuals (deontology), and from several relational perspectives (virtue ethics). This is not the place to investigate all these perspectives. Suffice it here to indicate that the epistemic difference between present and future events can give priority to present events, and thus can provide resources to manage temporal expansions of the moral imperative of medicine.
Asymmetries in ethics
Correspondingly, there may be sources for harnessing the expansion from negative to positive wellbeing. The moral philosopher Knut Erik Tranøy has argued that negative notions, such as bad, disease, and pain are logically more fundamental and definite than positive notions, such as good, health, and pleasure [137]. According to Tranøy negative notions tend to have different “moral weight” and are operationally more important than corresponding positive notions [137]. This goes for health and disease, pleasure and pain, but also for life and death, happiness and suffering, and for good and bad [137].
The asymmetry in moral imperative finds support in “negative utilitarianism” in ethics [138], according to which minimizing suffering has priority to maximizing happiness. With reference to Hobbes, Bernard Gert argues that “evils or harms play a much more important role in morality than goods or benefits” [139, 140]. The asymmetry also finds backing in Hans Georg Gadamer’s philosophy [141] and on the asymmetry between health and disease, where health is something given that cannot be produced or “effected” [142]. Virtue ethicists may argue that certain virtues, like compassion, are triggered by pain and suffering, but not by pleasure. It can also be claimed that avoiding pain are (near) universal ends for (human) beings [143] and that the conceptions of positive wellbeing or betterment are subjective and diverse [144].
Hence, asymmetries provide logical, conceptual, and ethical reasons for medicine to focus on negative notions, such as pain, suffering, and disease and can be used to manage the expansion of the moral imperative in medicine. This is by no means a full-fledged argument for the moral primacy of negative wellbeing to positive wellbeing. That demands a more elaborate treatment. The point here is merely to indicate that there are potential ways to manage the expansion of the moral imperative of medicine.
In sum, the traditional ways of addressing moral issues in medicine (aligning medicine with its basic concepts, with its ethos, with its basic goals, and with conceptions of making medicine better) may not work for addressing the expansion of the moral imperative in medicine. While this may seem discouraging, epistemic differences between present and future uncertainties and asymmetries in ethics between negative and positive wellbeing seem to provide resources to manage the expansion of the moral imperative in medicine. As future benefits seem less certain than present ones and as what is bad seems to be less difficult to define than what is good, it appears warranted to address present pain and suffering before future wellbeing and happiness. Accordingly, it can be argued that the moral imperative of medicine has a gradient from reducing negative to promoting positive wellbeing, and from present to future. See Fig. 3.
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