Department of Philosophy, University of Twente, Enschede, The Netherlands
Correspondence to: H. Procee, Department of Philosophy, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands. E-mail: h.procee{at}utwente.nl.
SIR, In their original and provoking paper Hazemeijer and Rasker [1] conclude: "Science has had and will have much to offer for the diagnosis and treatment of diseases. But society and medicine have to turn to philosophy rather than to science for the solution of treating and preventing syndromes like fibromyalgia".
Being a philosopher, I am honoured by this statement, but, more importantly, I am impressed by their analysis. The authors try to escape three reductionist strategies in handling a complex of vague complaints, as in the case of fibromyalgia: a reduction to physical causes, a reduction to psychological processes, and a reduction to labelling activities. They introduce a convincing argument in putting forward a much more intricate concept, borrowed from the philosophy and sociology of science: the concept of the therapeutic domain. In this domain, symptoms and laboratory results, the behaviour of doctors and of patients, personal expectations and messages in the media, language and organization, are co-evolving in a number of looping processes.
Such a concept has to fulfil three functions: (i) a descriptive one, i.e. analysing what makes fibromyalgia such a popular syndrome; (ii) an implicative one, i.e. analysing how, in a different therapeutic domain, a different syndrome would result from the same symptoms; and (iii) an intentional one, i.e. the recommendation to withdraw fibromyalgia from the list of serious syndromes.
The concept of the therapeutic domain is, in the view of Hazemeijer and Rasker, and also in my view, very fruitful, but does have two disadvantages. First, it is difficult to handle in empirical research because of the overwhelming number of interacting factors and looping processes. Secondly, it is problematic in transcending the line between descriptive and implicative analysis on the one hand and the intentional conclusion on the other hand.
For both reasons I would suggest that the authors use the smoother tools of semiotics put forward by Charles William Morris [2]. Semiotics is a philosophical theory of signs and symbols that deals especially with their function in artificially constructed, scientific and natural languages. Morris adapted Peirce's famous theory of signs in order to account for sociological aspects [3]. He proposed a threefold division into interpreter, designatum and frame of interpretation, which are in interaction with each other. Let us take as an example the group consisting of road users (the interpreters). When a member of this group sees a red traffic light (designatum), traffic rules (frame of interpretation) tell him or her to stop. Looking at a red bicycle will be completely unimportant within this specific frame of interpretation. The interpreter Robinson Crusoe saw some footsteps in the sand (designatum) and on the basis of his theory of natural causality (frame of interpretation) he concluded: There must be a Friday. These examples are illustrated in Fig. 1.
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This dynamic model is also apt for analytical purposes. Let us start with a doctor. She is a member of a particular school or group within the community of physicians; her frame of interpretation contains the theories and classifications of that school; the element in reality is a patient having some complaints. This doctor tries to explain and treat complaints according to the ruling theories of the school she belongs to. Business as usual. By accepting the complaints as elements in reality (as Hazemeijer and Rasker do), semiotics leads to different strategies of further investigation: (i) analysing the same situation from the viewpoints of the other parties involved (e.g. the patient himself; his family; his insurance company; but also different schools of physicians); (ii) analysing the rules of and relations in the group of physicians the doctor belongs to (by drawing a new triangle in which the group is the element in reality, the interpreters are sociologists, or the doctor in the role of a sociologist, and the frame of interpretation contains sociological concepts and theories); (iii) analysing the frame of interpretation of this school of physicians (with the help of another triangle, in which the doctor in the role of a philosopher, or philosophers themselves, conceptually scrutinize the theories and presuppositions at hand). Of course, strategies (ii) and (iii) might also be applicable to the other parties, mentioned in (i).
From this theoretical perspective, critical as well as constructive comments on the paper of Hazemeijer and Rasker may arise. The critical comment is on their discussion of symptoms and diseases. According to the semiotic model, a neutral or positivistic description (i.e. a description without some relation to an interpreter) of reality is out of order. In their section on this topic, the authors accept the difference between a nominalist (a syndrome is just a name for a complex of symptoms) and an essentialist (a syndrome mirrors something inphysicalreality) notion of disease. In accordance with their non-reductionist stance, they might be expected to accept the nominalist interpretation. Unfortunately, they do not do so. Therefore, I would advise them to embrace a strong nominalist position; this means accepting a description of a disease as real if it is converging in different (scientific) frames of reference [4].
My constructive comments are on the technique of stakeholder analysis, i.e. the analysis of all parties that are potentially involved. Making an extensive list of stakeholders, analysing their group characteristics and fathoming their frames of interpretation is much easier than the complicated sociological approach that Hazemeijer and Rasker mention. This technique may be very helpful in bridging the gap between the observational outsider perspective, which is dominant in the concept of the therapeutic domain, and the action-oriented insider perspective, which is central in their conclusion: For prevention and treatment of fibromyalgia we have to start by fundamentally changing the therapeutic domain [1]. The outsider perspective is neutral or symmetrical with respect to the different positions. It is therefore problematic in coping with the insider perspective. An insider acts on the basis of beliefs, interests and preferences. Semiotics is able to bridge this gap because the doctors themselves constitute one of the stakeholders in this approach. What are their group characteristics, and, more importantly, what is their frame of interpretation? The (implicit) answer given by Hazemeijer and Rasker is the central normativity of clinical practice: minimizing (physical) suffering and stimulating (physical) well-being. Because they observe an inverted placebo effect on the part of the patients (once the diagnosis fibromyalgia has been formulated, patients feel complaints at more and more tender points) and there is short-sightedness on the part of doctors (they do not look for deeper causal explanations), they might be correct in criticizing the social and therapeutic effects of the fibromyalgia syndrome.
In conclusion, the idea of the therapeutic domain is an interesting and powerful one. It is applicable not just to syndromes such as fibromyalgia but also to the accepted practice of medicine. We introduced semiotics to strengthen the analysis of Hazemeijer and Rasker, for empirical research as well as for normative and intentional analysis.
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