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The Disease Industry

In a recent article, “Sure, It’s Treatable. But Is It a Disorder?” the New York Times warns its readers to “brace yourselves for P.E. – shorthand for premature ejaculation”. If the pharmaceutical industry is to be believed, that may not be bad advice, since according them, “One in three men actually have the condition.” But the advice is not meant to be taken literally. What the reporter really meant was, “brace yourselves for ‘P.E.’ – shorthand for ‘premature ejaculation’”. According to the article, just as the makers of Viagra have in recent years introduced into the popular lexicon the name of a “modern man’s malady” and it’s acronym – ‘erectile dysfunction’, or ‘E.D.’, we can expect a similar effect as a result of the development and marketing of Priligy: a new pill for “men who ejaculate before copulating or within seconds of beginning.”

The interesting thing about drugs like these is that the condition that they address may not be recognized as a “disease” or “medical disorder” until the drug companies set out to market a “cure” for it. And medicalizing the issue is an essential part of the drug marketing strategy.

The New York Times reporter, Natasha Singer, describes the pattern this way:

[C]reating a blockbuster quality-of-life drug like Viagra involves more than just being innovative or being first. Sometimes it requires a drug maker to create and market a whole new category of disease.

The template goes something like this: Start with a legitimate quality-of-life issue — like fitful sleep or shyness — that does not yet have its own prescription medication and is debilitating to a few people a lot of the time. Next, position the quality-of-life issue as a medical condition with symptoms so common it covers vast numbers of people who had previously not identified themselves as having a health problem, or who thought they were just experiencing an occasional and normal annoyance.

Articles in medical journals with high estimates on the prevalence of the issue help convince doctors and journalists of its scope. F.D.A. approval of the new drug legitimizes the condition as a problem with a medical solution.

Although Singer thinks these drugs typically address something that is a “legitimate quality-of-life issue” for a few people, she seems skeptical that these drugs are marketed to address a genuine disorder with a medical solution. When the drug makers “position the quality-of-life issue as a medical condition with symptoms so common it covers vast numbers of people” who wouldn’t previously have thought they had a medical problem, it is implied that they are doing something dishonest or harmful. Singer concludes the article by citing Leonore Tiefer: a psychiatrist and academic who rails against “disease mongering” and claims that drug makers are trying to medicalize parts of daily life where there is simply a wide variation of normal: “When you tell someone they are a fast ejaculator, it makes it sound like there is a right time to ejaculate and, if you ejaculate before, it’s a medical problem … It is going to become a problem once enough publicity is given to it.”

One thing that this story highlights is the enormous practical and economic significance that hangs on whether a condition is understood as a “malady”, “medical problem”, “disorder”, or “disease”, or rather as just a normal variation. Fast-forward to the year 2020, and imagine how the story here might play out. If P.E. were to become widely thought of as a “disease” that you can be “cured” of, then we can predict with some confidence that men suffering it would be anxiously visiting their doctors and asking for Priligy or similar medications, and that doctors would consider themselves duty-bound to provide these treatments (assuming, at least, that these medications will be cheap enough to be covered by the relevant private health insurers or government health systems). If P.E. were instead understood to be no more than a description of part of a range of normal human responses, there will likely be much less stigma attached to having it, since there would be nothing thought medically “wrong” with a man with P.E. While a number of men with P.E. might still wish to change this feature of themselves, it would probably not be a matter of public policy to provide assistance to them in their self-improvement projects.

These diverging hypothetical scenarios raise a further, philosophical question. Is there an objective fact of the matter about whether P.E. is or is not a disease? Put another way: on either one or the other of the year 2020 scenarios above, would people generally have failed to recognize a truth? If we answer “Yes” to these questions, we might then ask whether we should be angry at the drug companies for distorting the public understanding in their pursuit of a fat profit, and we might ask whether the government (or medical scientists, or somebody else) should somehow intervene to prevent this behaviour. If we answer “No”, then we might instead wonder how a debate over the merits of seeing P.E. as a disease was ever even possible; how the implicit accusations of underhandedness and dishonesty against the drug companies could even have arisen. If there is no objective fact of the matter about whether P.E. is a disease or not, we might infer that the drug companies are just as entitled as everyone else to their subjective opinion or preference about it (and to try to change the fashion by marketing that view vigorously to everyone else).

The philosophical question is a subject of fierce debate, but it is my view that neither of the categorical yes-or-no answers just offered is particularly helpful, because neither of them presents a careful analysis of the sense in which the phrase “objective fact of the matter” is to be understood. It is implausible to think that P.E’s being a disease is an “objective fact” in the sense of a value-free, measurable and purely scientific fact, since it is plausibly one of the preconditions to a condition’s being a disease that it be bad in a certain way. The presence of a rare genetic mutation that happened to improve its bearer’s sexual performance, or of a rare strain of bacteria in the mouth that happened to improve its host’s digestion, would not count as diseases unless they had other side-effects that were in some way bad for that person, or for others. But this observation that value plays a role in determining whether something is a disease should not drive us to the other extreme, for it is no more plausible that all opinions about whether some condition is a disease or not are equally valid: no condition that is not actually bad in the right sort of way could possibly count as a disease, whatever one’s personal opinion of it, and neither could any condition that lacks a medical aetiology (which, granted, might be unknown to us). These are the reasons why homosexuality or drapetomania (a supposed mental condition that caused black slaves to flee captivity, described in the 19th century) are no longer considered diseases in Western medicine, irrespective of what any particular individuals happen to think.

Concluding that a value judgment is always implicit in calling a condition is a disease does not take us very far toward answering the objectivity question, since the nature of value judgments and their objectivity, or lack of it, is one of the deepest and most disputed philosophical questions there is. Here I can only submit a brief sketch of my own view, without arguing for it. I think that whether a thing is good or bad in a particular sense is a matter of whether the pursuit or avoidance of it is endorsed by the norms of a relevant practice. So whether a condition is bad in the sense relevant to deciding whether it is a disease is a matter of whether the treatment and cure of it is endorsed by, roughly, our medical practice. I also think that the norms of our medical practice are, in some ways at least, up to us as a society to determine. If I am right, then as the “disease industry” does its bit to push the norms of our medical practice in its favoured direction, we should be asking: what are the costs and benefits to us as a society of developing our practice in that particular direction, and should we be pushing back?

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