Michael Sharpe: Mind, Medicine and Morals: A Tale of Two Illnesses (2019) BMJ blog - and published responses

Abstract

In a recent paper, Sharpe and Greco (2019) argue that some clinical conditions, such as chronic fatigue syndrome (sometimes called myalgic encephalomyelitis), should be treated by altering the patient's experience and response to symptoms without necessarily searching for an underlying cause.

As a result, we should allow for the existence of 'illnesses without (underlying) diseases'.

@Carolyn Wilshire and Ward (2019) reply that this possibility requires unwarranted causal assumptions about the psychosocial origins of conditions not predicted by a disease model.

In so doing, it is argued that Sharpe and Greco introduce epistemological and methodological problems with serious medical consequences, for example, patients feel guilt for seeking treatment for illnesses that only exist 'all in the mind', and medical researchers are discouraged from looking for more effective treatments of such conditions.

We propose a view that integrates the insights of both papers.

We abandon both the strict distinction between disease and illness and the naïve unidirectional account of causality that accompanies it.

This, we claim, is a step towards overcoming the current harmful tendencies to conceptually separate (1) Symptom management and disease-modifying treatments. (2) Rehabilitative-palliative care and 'causal' curing. (3)

Most importantly, biomedicine and clinical medicine, where the latter is currently at risk of losing its status as scientific.

full text here

 

Also discussed here:

https://www.s4me.info/threads/micha...-published-responses.9729/page-18#post-291393

 

clicking this link no longer works .

 

This is the philosophical equivalent of saying: well there is no clear biological demarcation for races, and therefore since races don't exist, we can simply eliminate racism.

 

Looks like that sci hub domain is down.

Alternatives:

https://sci-hub.ee/
https://sci-hub.se/
https://sci-hub.st/

 

This is probably the best framing of the naiveté of this cheap philosophy. Love it. This approach misses the whole point, focusing on superficial trivialities.

It's no different than speculation about natural laws in the 18th century or earlier, with not a single person having intuitively come up with stuff like electromagnetism. Without actual science to arbitrate, in the end this is no different than a drunk-filled debate. Completely pointless mental masturbation and circle-jerking.

 

Try this one : https://sci-hub.ee/http://dx.doi.org/10.1136/medhum-2019-011807

 

The only way to discover what a disease is is to put forward a testable hypothesis and carry out the experiment. You follow the differences. That is how they discovered bacterial diseases and how to treat them. If they had looked at the similarities they would have concentrated on fever or spots and we would not have antibiotics or vaccines.

 

Fantasy: there is no harm in arbitrarily dismissing some illnesses and systematically refusing to do anything more than clowning around because there is no possible harm, the symptoms are silly anyway, the patients are icky and what's the worse that could happen anyway?

Reality:

https://onlinelibrary.wiley.com/doi/full/10.1002/mco2.13

Hold on, hold on, I think this needs to be emphasized more because I've made that point months ago:

Hmmm, more:

Ahh, much better. Some points apparently have to be emphasized for good.

The willful ignorance of these jerks leaves our entire civilization weaker. It is a massive obstacle to getting this civilization-threatening pandemic under control and still they will try to sell their stupid astrology-level junk. This ridiculous ideology has already destroyed millions of lives so this is all on top of this, obviously. Because if a chronically ill patient dies without a respectable diagnosis, did they really even exist?

 

Well, well, well, if it isn't the consequences of people-like-Sharpe's actions.

The reality of concepts like "illness without disease" is that the illness does not disappear, it just becomes more dangerous and all that harm goes unnoticed. Just like banning abortion does not result in fewer abortions, just more deadly ones. Medicine abandoning sick people to fend for themselves only leads to all harms being unnoticed. That is, until the amplified harms are noticed, but the recklessly irresponsible decision to abandon them in the first place is somehow left out despite being wholly responsible.

It's absolutely right that this is a serious problem but that problem is secondary to the primary dereliction of duty motivated by stupid nonsense like false attribution syndrome, rejecting reality and substituting their own. I don't know what people expected to happen but clearly they did not expect the predictable and that's an incredible failing in itself. And for a damn category error, no less. Only bad politics creates such a toxic mess of failure, not a single field of expertise even comes close to this level of failure.


Dubious Alternative Lyme Treatments Are Killing Patients

https://www.bloomberg.com/news/feat...s-alternative-treatments-are-killing-patients

Mocking, laughing at, maligning, insulting, eye-rolling and dismissing with prejudice do not, in any way, amount to "recognizing". This is what happens when you abandon sick people without professional medical support. They're still sick. That does not change. All it does is make them worse. All for clowns like Sharpe to wax philosophically about ridiculous nonsense they are completely clueless about.

 

Thanks for alerting me to this. Its taken me ages to post about it, because every time I tried to wade through this word stew, I lost heart, and decided to do something else.

Just a quick scan through the paper and I see a lot of what I call "red flags":

Citations to authority: Claims or statements of opinion followed by some sort of citation designed make it look "valid" or at the very least "scholarly". Often the cited text turns out to have nothing to do with the current claim. But even when it does, this is still academic sleight of hand, imo.

In my view, when you cite work, you should specify the function of the citation - whether it is to empirical work that reports the outcome being discussed, or to a previously proposed idea or argument or theory.

Name dropping. When you mention someone by name in the text, when it does not advance your argument in any way. The purpose is to make your work look erudite. e.g. "‘the principle of empiricism’—formulated by John S Mill and taken up, among others, by William James and Karl R Popper..."

Red flag words: Words that sound good but are not easily defined, and serve largely to beautify the text and make the writer appear erudite. They can also be used to obfuscate. e.g., intersubjectively, hermeneutic-normative.

Pretty sentences that are so vague their claims cannot be put to any sort of test, not even a logical one. Some examples below.

I was going to try to translate each claim into plain English, and then speak to it, but some statements are not easy to pin down. Whether by design or accident, I don't know. Here's what I mean (my bolding):

What do they mean by an "intersubjectively testable notion"? What do they mean by a notion even? Is it an explanatory theory?

What does it mean to say this "notion" needs to be "testable"? If you mean an explanatory theory from which we can derive testable predictions, then say that.

In what way is "intersubjectively testable" different from just "testable"? You mean not made up in your head? That's almost a given, is it not?

And finally, what is an "intersubjectively testable path leading from illness to the remaining causal network of all our experiences"? Is that a causal model of the illness experience that includes every damn thing the person has experienced, every way in which their body has failed them, and everything in between? A model for each person? Good luck with that.

And finally what are these "entities" that S&G mistakenly suggest can exist independently of each other? Is this about S&G's claim that some "sicknesses" can be mainly or even entirely caused by psychosocial factors? Then why not just say that?

"methodological autonomy and dignity?" Wtf is "methodological dignity"? Do you mean that you should treat individuals with dignity? Then say that. How can some methodologies be more dignified than others? Honestly.

What the *** does "the clinical or psychosocial dimension of health and sickness" mean? It sounds so lovely and sensitive. But what exactly is the claim? Is it a causal one? That thoughts, feelings, or social contexts can somehow play a causal role in "sickness", and addressing them can ameliorate or even cure "sickness"? If so, then you would have to make the argument based on the case or condition, based on evidence (don't think psychosocial interventions are much use if you have ebola, or if your head has been severed from your body).

Or is the claim merely that sickness impacts on people's thoughts, feelings and social circumstances, and those effects can be unpleasant in their own right? The difference in these two claims is huge, and have entirely different implications for the sorts of interventions they support.

Hmmm

What a merry verbal dance. They are trying not to say "organic disease", because it is so "dualistic", so they thought they'd better cover it up a bit.

Putting aside the red flags here, they seem not to understand that a model of causation need not be "organic". What does that even mean? The very word is founded on dualistic assumptions. Instead, our model proposes that causal explanations can be phrased at any level of description - including the social and the psychological - and the choice of level is determined by its usefulness at capturing the key causal mechanisms. We simply don't think psychologically phrased causal claims should be made as a default position, but rather that they should be supported by positive evidence - just as is the case with any other causal claim.

The bit below is a reference to our 3-catoegory framework for understanding causation in health and medicine

Yes, any "purely subjective illness" for which we have no evidence to support a causal explanation is - by definition - an illness for which we have no causal explanation. It is incorrect to insert the word "biomedical" into our argument, we make no claim that the causal evidence needs to be biological. Our examples are designed to illustrate the problems with positing a psychological cause based merely on the absence of evidence for other causal mechanisms. They are rather persuasive there.

Do we really need to spell this out? Psychosis is in this third category. Bipolar is in there. Are we claiming that just because they are not explained yet, that they are not real? What a massive straw man! As for "forever located", I think those doing excellent work on these conditions might be a little insulted by that!

Okay, I've lost patience, so will stop there - and maybe have a go at the remaining bits of the paper another day.

 

I have come to think that it is in the highly specialised language developed by this particular group of BPS adherents that is what helps them to continue to believe in all this nonsense.

If the concepts they work with were to be laid bare and discussed with precision and clarity they themselves would see the folly of it all. But the obfuscation is actually for their benefit.

It is as you say (CW) erudite sounding. It's as if that is a facsimile for actual content that can be independently validated in a scientific forum.

The obfuscation serves to protect them as only those who don the robes of the elite group of BPS'ers can penetrate the meaning to see the light of the 'brilliant' ideas behind them.

It is one of the things I personally find most abhorrent about the position they take vis a vis patients. It's self-serving delusion.

 

I think that the problem with this paper, which I have not tried to analyse, I no longer have the capacity, is that the authors and probably Sharpe as well, have not looked at how the "illness" concept was originally used in ME type cases. I am assuming that it was Eisenberg, in 1977, who first made this distinction between illness and disease. Perhaps Mechanic, or even Pilowsky did earlier, but I have seen no evidence for that.

Unfortunately Eisenberg then referred in 1985, and again in 1987, published in 1988, to "chronic brucellosis" which he equated with ME, as being a "spurious disease construct", characterised as " a pattern of illness behaviour fashioned out of the experience of an acute infection in psychologically predisposed people, a pattern reinforced by medical responses which sanction complaints by ascribing them to disease".

Take away the cancer patient's fatigue and they still have the cancer. Take away the ME patient's fatigue (EDIT and other illness behaviour) and there is nothing there.

Its the Imboden, Canter, Cluff problem again.

 

There seems to be an enormous lacuna in these discussions. I have to admit that I do not understand it. The discussion about the distiction between illness and disease informed much of the proceedings of a 1985 international conference in Toronto. The papers are published, at great expense, in Illness Behaviour: a multidisciplinary model eds McHugh and Vallis. Sharpe will be well aware of this.

There is a paper by Arthur Cott on The Disease-Illness distinction: a model foreffective and practical integration of behavioural and medical sciences. Kleinman also discusses it in Illness Manings and illness Behaviour. Ther are various other references

Somewhere, in a reference which Ihave now lost, it was said that the dichotomy went back to a paper by Coe in 1960 or 61.

Possession of this material is rather like the capture of teh Enigma machine. It allows for the breaking of all the codes.

Cott says in the chapter Illness is the problem: In the context ofthe disease-illness model described above, a major aspect of medical health problemshas less to do with disease than with illness. In other words the problem is with illness rather than disease! The problem is illness which has no disease determinant or is discrepant with that which can be accounted for on the basis of disease alone.

Sometimes it seems that psychiatrists are more secretive than the Masons. I know not whether they have similar rituals.

 

It's a bit ironic that they insist on separating illness and disease while saying body and mind aren't separate.

My suspicion is that the motivation for separating illness and disease is to create jobs for practitioners of psychosomatic medicine (the would-be experts for illness without disease) and enable the justifiable discrimination against patients.

Do these older articles confirm this?

 

My interpretation is that it was these views which led from the disease centred conditions ME and PVFS to the purely illness behaviour model of CFS, falling happily within the domain of psychiatry. I will try to unpick this, but there are 400 pages of dense script, which is not ideal. In answer to the question it does seem that the solution to the problems of illness seems often to be a mutidisciplinary approach, according to various sources.

Much of the conceptualisation within the book seems to have some merit. The difficulties arise in respect of unknown unknowns. It is not clear how much could withstand hostile cross-examination.

 

For the sake of accuracy I should say that the paper is by Coe R M (1970) in Sociology of Medicine quoted in

What remains ill-defined, howeve, is the notion of "illness". Writers such as Coe (1970) have emphasised that "illness" and "disease" are not the same thing. "Illness" refers to the individual's subjective experience of a "disease", which in turn, is essentially a biological concept. The definition of what constitutes "disease" is often difficult. Disease can be construed as a constellation of objectively recognised characteristics of illness.

Abnormal illness behavior: a review of the concept and its implications. Issy Pilowsky.
In Illness behavior; a multidisciplinary model eds McHugh and Vallis 1987

This definition would not appear to allow for "illness"" in the absence of " disease", which one might think would cause dificulties for subsequent users of the terms.

 

It seems to be the same merry dance I mentioned in relation to the Tesio quote above. They are tripping over themselves to avoid saying "organic" versus "psychological". So instead they call disease "a constellation of objectively recognised characteristics of illness".

But this is not what they really mean. "A constellation of objectively recognised characteristics of illness" is not limited to medical test results, scans and observable signs. There are many other types of "objectively recognised" characteristics of illness - for example, spider avoidance behaviour is a measurable and objectively recognised characteristic of spider phobia and low scores on the Yale-Brown scale (a self-report scale) is an objectively recognised characteristic of obsessive-compulsive disorder.

Of course, they don't mean these, because they don't really mean "objectively recognised", they mean "organic".

 

It would be interesting to know what they think there is to cause "illness" other than biology.

I think we are getting closer to understanding what they thought they were dealing with. Eisenberg made a reference to "post brucella somatisation.

Imboden referred to it as a "conversion reaction", protecting against various dysphoria. Those who have quoted the Imboden, Canter, Cluff papers to explain the condition have not dissociated themselves from that view. I will be posting links to these papers on the Chronic Brucellosis Papers thread.

 

This is something i did not expect

This work was supported in part by a Public Heahh Service Special Fellowship (MH--8516) from the National Institute of Mental Health. During the period of the fellowship the author was affiliated with the Medical Research Council Social Psychiatry Research Unit, Maudsley Hospital. The author is indebted to Dr. JOHN WING for his helpful comments.

Response Factors in Illness: The Study of Illness Behavior ::" DAVID MECHANIC University of Wisconsin, Madison, Wisconsln/U.S.A
www.researchgate.net/publication/226840612_Response_Factors_in_Illness_The_Study_of_Illness_Behavior/link/544a70c40cf2f2f6012ada36/download

This 1966 paper is intersting in that Mechanic seems to be recognising the distinction between Illness and ilness behaviour and disease, but has not yet expressed it in terms of the dichotomy of illness and disease. One reads it and thinks that he has a point. But that he is missing larger ones.