Reckonitis: A Cognitive Deficit of Social Origin

RECKONITIS: A COGNITIVE DEFICIT OF SOCIAL ORIGIN MlKEL AICKIN* Introduction The taxonomy of human diseases has become sufficiently broad to include those that emerge from the conditions of a particular society, but it is not yet sufficiently inclusive to comprise those pathologies that disorder the perception of physiologic and psychiatric disease states. The name for the superficial study of disease occurrence, epidemiology, is comprised of the Greek epi ("upon") and demos ("the people"), and so one might think of these perceptual disorders as epidiseases, cognitive states that exist upon a disease. They are, therefore, afflictions of those who study diseases. An example is reckonitis, which is the inability to carry out the computation ofdisease incidence or probability. It is a specific dysfunction in understanding the frequency of occurrence of disease, which forms an impenetrable barrier to all further comprehension of disease etiology, prevention, diagnosis, or treatment. This epidisease has not been well characterized, despite its evident historical prevalence up to the present era. As a first step toward establishing an appropriate classification, I will examine one particular manifestation, the inability to compute the lifetime risk of breast cancer, as expressed in two overt, acute clinical cases. Clinical Presentation The vast majority of individuals who cannot compute the lifetime risk of breast cancer constitute the subclinical population, because they never try to do the computation and so their condition never becomes evident. Since they are, for the most part, not medical or health professionals, one can legitimately question whether their epidisease has, in fact, presented itself, * Center for Health Research, Kaiser Permanente Northwest Division, 3800 N. Kaiser Center Drive, Portland, OR 97227.© 1998 by The University of Chicago. All rights reserved. 0031-5082/98/4102-1057$01.00 Perspectives in Biology and Medicine, 41, 3 ¦ Spring 1998 | 349 or whether it has any measurable consequences. Thus, in delineating this particular form of reckonitis, we must turn to the rare cases in which it has been expressed in nearly pure form. These are instances in which afflicted individuals have chosen to exhibit their condition publicly. The first and foremost case is Walsh [I]. In his book, the third chapter "Cancermania" is for all intents an indictment of the claim that currently one woman in nine will suffer from breast cancer during her lifetime. One prominent feature ofbreast cancer reckonitis seems to be a breathless sense of almostjournalistic glee in debunking the putatively exaggerated claims of health authorities. Thus we read of the American Cancer Society's shameless scare tactic to influence women: If you know anything about breast cancer, you're waiting to hear the statistic that sticks in most people's minds. It's a shining example of the manipulation of risk assessment . . . and the distortion of odds. It's defended as an exaggeration that means well, but it probably does more than any other statistic to make people doubt all risk numbers they hear. It's 1 in 9. [1] Another significant feature of reckonitis is the reduction of computation to rhetoric. Numbers are, in this deconstruction, simply words that can be construed however one wants, without regard to the fact that—unlike other words—numbers have to obey certain rules and may be subject to rather precise definitions. In this clinical presentation, therefore, one can read that Technically, the Cancer Society's l-in-9 number is misleading because it is an incidence rate. Most people confuse the incidence rate with a mortality rate—which it isn't. Even accepting the Cancer Society's questionable assumptions, the mortality risk for breast cancer would be 1 in 28. [1] This confabulation confuses a lifetime probability with an incidence rate (a factual mistake) but places it next to a correct statement (a breast cancer incidence rate is not a breast cancer mortality rate) . The author then goes on to assert an undocumented "mortality risk," which is completely undefined even in a technical sense, although it is again true (as we will see) that a woman's lifetime breast cancer mortality probability is about 1 in 28. We will also see that there is nothing "questionable" about the American Cancer Society's assumptions. It appears to be an important feature of this...