Pigeonholing illness: Medical diagnosis as a legal construct

Disease definitions and clinical judgments routinely affect coverage and re imbursement decisions by health insurers, the licensing determinations of r egulatory agencies charged with reviewing new therapeutic technologies, evi dentiary and substantive rulings by the judiciary in personal injury lawsui ts and criminal trials, eligibility decisions in disability programs, and t he resolution of claims before workers' compensation tribunals. This relian ce on the definition and identification of disease by the medical professio n fails to appreciate the extent to which our conceptions of illness are so cially constructed rather than based on value-neutral scientific data and t he application of technical expertise. Just as social forces shape medical practice, legal institutions have influ enced nosology and diagnosis, but the nature and consequences of their effe cts on the definition and identification of disease have gone largely unnot iced. By virtue of their often uncritical reliance on clinical judgments, a gencies and courts have, to some extent, distorted and even corrupted medic al practice, thereby interfering with the primarily therapeutic purposes un derlying diagnostic decisionmaking by asking physicians, psychiatrists, and clinical researchers to provide answers to difficult legal and political q uestions. To the extent that medical professionals make diagnostic judgment s to serve non-therapeutic purposes, they may work against promoting the be st interests of their patients and society.