Editor’s Introduction: The Diagnosis Issue

It would be hard to imagine medical care without diagnosis, so pivotal is it to how Western medicine is practiced. Diagnosis is one of medicine’s principle tools, bringing with it as it does an explanation for what ails the sick person, an idea of what the treatment options might (or might not) be, a prognosis, and much more. It assigns responsibility for illness, within medicine and outside. It will determine which specialty or sub-specialty can take care of which disorders. It also explains causation, pointing the finger variably at the patient for what she ought to have done, or to the gene for what one can do little about. Diagnosis structures and explains relationships as it provides the impetus for the sick person to consult the doctor, cementing authority at the same time as it reinforces patience, and submission.

It is a powerful thing, diagnosis, performing tasks well beyond those described above. It summarizes features of cases, a kind of shorthand for capturing a long description in just a word or three. With the simple diagnostic word or expression, we can understand much, much more. “Bacterial pneumonia,” for example, evokes chest pain, shortness of breath, fever, crackly breath sounds, and a milky X-ray. It leads to antibiotic treatment, rest, and sick leave. It doesn’t, on the other hand, reveal the curious (and maybe unrelated) neck pain that was the patient’s main concern and incited her to consult. So while diagnosis summarizes, it also obfuscates, bringing particular aspects of suffering to the fore and leaving others in the shadow. That which doesn’t fit into a diagnostic profile recedes as the sense-making diagnosis profiles the case.

We hear about diagnosis every day, outside of the doctor’s office or the corridors of the hospital, as diagnostic language is increasingly used to describe our suffering: we swap sadness for depression, distractibility for ADHD, and shyness for social anxiety disorder or social phobia. We self-diagnose, with diagnostic apps and online check lists. Direct-to-consumer advertising occupies popular ground, reminding us of the range of diagnoses that can afflict us, and prompting us to seek advice in case a particular remedy could solve our ills. All of this changes the way laypeople speak about, understand, and make sense of illness. They use language and knowledge that previously might have been the purview of the physician alone.¹ People use diagnoses to make friends and social links, joining online support groups for confirmed (and even only-suspected) diagnoses. They force open the doors to diagnostic power, creating, destroying, and replacing diagnostic labels via social advocacy and political action. Just as homosexuality left the pages of the DSM, PTSD found inclusion, in great part due to the work of non-diagnosticians to bring attention to what people in the streets felt and believed about these states (Kutchins and Kirk 1997; Scott 1990).

Diagnoses are arrived at with far more than just clinical judgment in mind. The choice of diagnosis will be shaped by coding: the manner in which an individual’s condition is identified in medical records can optimize or alternatively curtail insurance coverage, can increase, or minimize, distress. Where private insurance dominates medical funding, general practitioners might employ coders to evaluate their diagnostic work and determine which diagnostic category could produce the best coverage for their practice and the funding of care. Or they could use an app like MarginMaker ICD-9 or Sat ICD-9 Coder. But similarly, a diagnosis could be chosen with the future of the individual in mind. The notation “adjustment disorder” (signifying a short-term psychological response to an outside event) in a patient chart would less likely result in her refusal of future care than would a “major depressive disorder, recurrent episode,” which implies a constitutional tendency towards depression. Similarly, pursuing better social outcomes, a doctor might choose a different diagnostic explanation for cause of death in the presence of suicide to enable the deceased to be buried in hallowed ground and to protect the family from the associated stigma (Bowker and Star 1999). Or the diagnosis of migraine...