I have now been a doctor for over thirty years and a neurologist for twenty-five of those,” Suzanne O’Sullivan writes early in The Age of Diagnosis: How Our Obsession with Medical Labels Is Making Us Sicker. “In recent times, I have grown particularly worried for the large number of young people referred to me with three, four or five pre-existing diagnoses of chronic conditions, only some of which can be cured.”
I am not a doctor and indeed have no medical expertise. But I imagine there are few people in my position—an American, a millennial, the mother of school-age children—who have failed to notice what O’Sullivan more intimately sees: that diagnoses are on the rise.
There’s a certain delicacy in discussing this, a delicacy O’Sullivan acknowledges. Outside the unconstrained bombast of television talk shows and hot takes on social media, out here in the normal world where it still matters how we speak to and about one another, this is a difficult subject to broach for those of us without medical credentials. Certainly, I have neither the standing nor the appetite to question a single diagnosis.
But I do question the society-wide rise in diagnosis and the assumption in so many medical contexts that more screening, more testing, more diagnoses, and more treatment are always best. O’Sullivan questions all this too in a book that is at once fascinating and informative—and surprisingly relevant to leaders in today’s church.
More illness, less stigma, or overdiagnosis?
O’Sullivan isn’t unusual in encountering more patients with more diagnoses. The bare fact that diagnoses are proliferating—and for some conditions, proliferating rapidly—is not in dispute. The question is why this escalation is happening, and O’Sullivan posits three possible explanations.
It could be that we are simply sicker than we used to be: prone to inactivity, awash in microplastics, beset by the anxieties of modern life. Or it could be that we are no sicker than before but more willing and able to recognize and treat illness as medical technology advances and social stigmas decline.
There’s truth to both explanations, O’Sullivan grants, but ultimately she puts more weight on a third:
It could be that not all these new diagnoses are entirely what they seem. It could be that borderline medical problems are becoming ironclad diagnoses and that normal differences are being pathologised. These statistics could indicate that ordinary life experiences, bodily imperfections, sadness and social anxiety are being subsumed into the category of medical disorder. In other words: we are not getting sicker—we are attributing more to sickness.
There are two related problems here: overdiagnosis and overmedicalization. As O’Sullivan defines it, an overdiagnosis is technically “correct,” but it “does not benefit the patient and may arguably do harm.” By overmedicalization, she means the habit of giving medical labels to “ordinary human differences, behaviour, and life stages,” like treating normal “ageing, poor sleep, sex drive difficulties, menopause, and unhappiness” as illnesses to be medicated, perhaps for life.
Because the logic of overmedicalization is easier to grasp, O’Sullivan devotes most of her attention to overdiagnosis (which itself can encourage more overmedicalization). Throughout the book—which explores conditions as different as Huntington’s disease, cancer, autism, ADHD, Lyme disease, and long COVID—she emphasizes a core distinction: whether a diagnosis is narrowly correct or genuinely beneficial.
O’Sullivan lists a litany of assumptions that might seem preposterous to question: “that any diagnosis is better than no diagnosis; that tests are more accurate than doctors; that test results are objective, immutable truths; that early intervention is always for the best; that treatments that work for one set of people will work equally well for others; that diagnosis is something fixed and definite; that pre-emptive testing is the surest way to long-term health; that more knowledge is always for the best.”
But the book mounts a compelling case for skepticism toward that received wisdom, pairing expert explanation of how various tests function with stories of patients from O’Sullivan’s own practice and beyond. The book details how some diagnostic criteria have expanded to sweep in people exhibiting no well-established symptoms of their ostensible disorders. It tracks how patients are hurried along to testing and intervention of dubious necessity, notwithstanding the clear risks to their peace of mind. And it laments that few in the medical profession have paused the rush of technological progress to ask, Could this do more harm than good?
What we know and how we experience it
As it surveys overdiagnosis in various fields of medicine, The Age of Diagnosis always takes patient suffering seriously. As a neurologist, O’Sullivan makes a point of validating psychosomatic pain alongside more familiar psychological and physical disorders. “Psychosomatic” does not mean “fake.” In all the cases she explores, even those where her skepticism of the patients’ diagnoses runs high, her compassion is clear. “The struggles are real,” she says; it’s just that “medicalising them may not be the solution.”
The stakes are high because inappropriate medicalization is risky. We may be tempted to shrug at overdiagnosis. Perhaps it’s unnecessary, but if it’s reasonably correct and if the patient wants it, what’s the harm?
The harm, as O’Sullivan writes, is that applying a diagnostic label is not a small or neutral act. It can reshape our self-conception and personal identity, rewrite our expectations for the future, and even—through the complex and imperfect interplay of body and mind—generate symptoms we otherwise would not have experienced, on balance reducing quality and even duration of life.
Simply “knowing you are at high risk of a disease could change how you use your body and how much you trust it,” O’Sullivan argues. “Worry and uncertainty creates fertile ground for the misinterpretation of every normal illness and bodily change. A medical label is not an inert thing.”
The book never explicitly discusses epistemology, that branch of philosophy concerned with knowledge and how to acquire it. But O’Sullivan is raising essentially epistemic questions: What can we know about our bodies and their futures? What should we want to know? When are we deluded about the extent of our understanding? How should we act on what we do understand? And how does the knowledge available to those in the modern West—so far beyond what much of today’s world, to say nothing of our ancestors, can access—influence us in ways we may not even recognize?
It is tempting to think we should always know as much as we can. It’s tempting, too, to envision modern medicine delivering that knowledge as surely and comprehensively as any hard science does. The Age of Diagnosis poses an incisive challenge to both notions. It asks readers to consider that good intentions are not the same as good outcomes and that more (or more high-tech) medicine is not necessarily the better alternative.
O’Sullivan is not a tech skeptic; in fact, my one substantive critique is that she is much too blasé about teen screen time. Nor is she reflexively critical of elite expertise or institutions. She is a doctor who wants to do right by her patients and has come to understand that doing right may sometimes mean doing less.
A book for every pastor
Again and again in the patient stories she shares, O’Sullivan raises the matter of how to care for people as they experience the ordinary hardships of human life. Overmedicalization has expanded disease definitions, she argues, “so that over time, people who would once have been considered healthy are drawn into the disease group.”
That may seem well outside the pastor’s purview, and no doubt it is where some diseases are concerned. Seminary doesn’t give you any special expertise in discerning signs of cancer or determining what blood sugar levels qualify as prediabetic.
But with other conditions, particularly those affecting behavior and mental state, O’Sullivan’s insights hold vast relevance to pastoral ministry and the larger work of the church. In fact, I would recommend this book to any pastor in the United States, and particularly pastors of churches with large populations of children and young adults. The Age of Diagnosis can equip pastors for tasks of both exhortation and encouragement.
Pastors are not doctors, of course, and they should have all due humility about physical and mental health care. But they should hesitate to bench themselves when they encounter physical, mental, and emotional distress. In some cases, what’s intended as deference to medical expertise may actually be abdication of pastoral responsibility toward suffering with some spiritual component.
The effects of such abdication can be far-reaching and deleterious. “The words we use to describe our suffering make a huge difference to how it is perceived,” O’Sullivan says. Attributing distress exclusively to internal biological pathologies (rather than, say, behavioral or spiritual responses to external stressors) may feel validating for people. It tells them their suffering is real, and often it is real.
But it may also unintentionally tell them that they have no agency over that suffering, that it is solely about chemicals and entirely separate from the state of their souls. “I fear that a view that talks too much about internal biological processes makes people passive victims of their medical disorder which takes away their control,” O’Sullivan warns. “A person who believes they are incapable behaves as if they are incapable, which provokes others to treat them as if they are incapable, and so the cycle feeds back into itself.”
Christians must be willing to reach for medical explanations and treatments when needed. Yet as people who believe in spiritual realities and the necessity of the church, we should be open to spiritual and relational explanations of suffering too. Pastors can’t change people’s brain or blood chemistry. But they can exhort those who are suffering to examine and change how they behave, how they think about themselves, how they respond to the difficulties and evils we will all encounter as aging people in a fallen world.
As for encouragement, O’Sullivan suggests that this, more than medication or other treatment, is what many patients fundamentally want when they seek a diagnosis. Several times throughout the book, in what reads like an unintentional echo of biblical language (like Mark 16:18, KJV), she speaks of patients’ deep gratitude for doctors who take the time to “lay hands” on them.
“Society has a general lack of caring institutions, except for medical facilities,” O’Sullivan observes. “This means that physical illness is always prioritised and so it is more straightforward when distress is expressed as a medical problem,” which will bring “a person under the jurisdiction of one of the few institutions available to offer support in a crisis.”
But there is another institution to offer such support—a very common institution, an institution with no bills or fees, an institution open to all comers, diagnosed or not. It is the church. And indeed, Christians reading O’Sullivan’s concluding comments can justly relate them to an absence of pastoral care, good theology, faithful practice, and thick church community:
People are struggling to live with uncertainty. We want answers. We want our failures explained. We expect too much of ourselves and too much of our children. An expectation of constant good health, success and a smooth transition through life is met by disappointment when it doesn’t work out that way. Medical explanations have become the sticking plaster we use to help us manage that disappointment.
And now the public and medical professionals are caught in a folie à deux [or “shared psychosis”] that we are struggling to acknowledge. There are many more questions put to medical professionals than we can actually answer. Worried people come to see us all the time hoping for a coherent explanation for their problem. We feel our patients’ needs and are relieved if we have an explanation to give. It may be that what some of those people really wanted was reassurance, but increasingly, the answer seems to come in the form of a label.
I am grateful to live in the age of modern medicine, the time of vaccines and anesthesia and antibiotics. I recently read a remarkable history of the plague as it moved through the United Kingdom in the mid-1300s, and it is sobering to grasp just how clean, safe, and healthy our lives are compared to those of our forebears. Whatever our rightful frustrations with our medical and insurance systems, we objectively have it very, very good.
Yet medicine is not the only answer to human woes—far from it. The Age of Diagnosis is right to caution us against overreliance on medicine’s still-imperfect remedies, to insist that sometimes we are not depressed but sorrowful, sometimes not clinically fatigued but overworked and underpaid, sometimes not hyperactive but undisciplined, sometimes not sick but sickened by sin (or the sins of our neighbors). I have already bought a copy for my church.
Bonnie Kristian is editorial director of ideas and books at Christianity Today.
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