esanum: Prof Maio, why is the definition of health and illness sometimes not so clear and simple and why is it important to think about it?
Prof. Maio: Health is a very demanding concept because it is expected to fulfil a regulatory function that it often cannot fulfil. It is very demanding because it contains the claim to something overarching and generalising. At the same time, however, the term inevitably has to do with subjective feelings and social perceptions, without the concept being able to merge with these. This field of tension between objective claim, subjective meaning, and social construction makes the concept of health a versatile one. At the same time, a great deal is expected from this concept. This is because claims and political demands can be derived from it. This applies even more so to the concept of illness.
esanum: Which definition is conclusive for you? So what is illness? And what is health?
Prof. Maio: First of all, illness is a normative term, which is associated with a challenging character. The very concept of illness implicitly conveys undesirability. Furthermore, illness is a concept of legitimisation. It is used to legitimise claims to treatment measures and claims to relief. Health is fundamentally related to development potential, to the ability to cope with adversity, both physically and mentally. Health must be seen as a basic ability to develop and to overcome adversity. Health is therefore less a state and more a basic disposition that manifests itself in crises.
esanum: We have more and more diagnostic test options at our disposal, such as genetic tests or virus tests. Where do you see the limits or even dangers of the informative value of these data?
Prof. Maio: Of course it can be helpful to carry out predictive tests, but as a rule there is an exaggerated collective expectation of prediction, and it is not sufficiently considered that predictive tests can have a psychologically stabilising effect, especially in the case of late-manifesting diseases. Basically, the tests mean a detemporalisation of the disease, because they bring the disease that will occur in the future completely into the present, thus anticipating the future with the possible consequence of an early deterioration of the patient's state of health. If the tests are used carelessly, there is a risk of losing impartiality. A balance must therefore always be struck between making provisions for the future and living unbiasedly in the present.
esanum: Illness can have physical and psychological causes - and the two are connected. Do we tend to underestimate the psychological aspects?
Prof. Maio: Absolutely, both by doctors and by the patients themselves. This has fatal consequences, because for many pain patients, for example, it leads to an odyssey through many doctors' offices in search of somatic confirmation of their pain. As long as they do not have this somatic equivalent, they do not feel that they are being taken seriously. And this simply requires a change in thinking. Pain can have a psychological cause that needs to be recognised, by the health system, by patients, and the population in general. The subjective experience should be taken much more seriously and it should be recognised more than before that there is suffering without objective findings and that this suffering must be taken seriously; chronic pain is a relevant example of this.
esanum: Can I even decide for myself whether I am healthy or ill - by trusting my own perception?
Prof. Maio: Your own perception is of course very important. We should also take people seriously when they say they are suffering and recognise that there is not always a somatic correlate to their suffering. This is the only way we can prevent an excessive biologisation of health. The challenge lies in not allowing arbitrariness to arise in the use of the terms health and illness when recognising psychological causes. In order to be able to talk about these terms in a meaningful way, we have to bring together subjective feelings with commonly shared concepts. Society must agree on which deviations from the statistical mean are considered to be illnesses and which are not.
This shows that these terms should neither be naturalised nor subjectivised. Health is not a purely subjective concept; we use it to make a claim to generalisability, to social acceptance. This means that society has a say in determining health. Health is therefore not a purely subjective term, but an intersubjective one. In order to be able to speak of health, an agreement must be found between the individual subject and society, which simply means that health must be intersubjectively verifiable in a certain way.
Prof Dr Giovanni Maio is a physician, philosopher and university professor of medical ethics at the Albert Ludwig University, Freiburg, Germany. He deals with the ethical limits of the economisation and mechanisation of medicine, and challenges the perceptions of health and illness in modern medicine.