Underdiagnosis of Health: A Key Driver of Overdiagnosis of Disease.

BACKGROUND: In reducing medical overactivity and healthcare waste, there is much focus on reducing overdiagnosis of disease. Surprisingly, there is little attention on the underdiagnosis of health. OBJECTIVE: This article investigates how avoiding underdiagnosis of health can reduce medical overactivity. METHODS: Conceptual analysis drawing philosophy of medicine and medical ethics is used to address five specific research questions: 1) What is health? 2) What is underdiagnosis? 3) What is underdiagnosis of health? 4) What is the relationship between underdiagnosis of health and overdiagnosis (of disease)? 5) What are the implications of the answers to questions 1-4? RESULTS: Underdiagnosis of health is contingent on the concept of health, e.g. health as wellbeing, capability, homeostasis, well-functioning, sense of coherence, resilience, and ability to realize vital goals. Underdiagnosis is reconceptualized as an epistemic omission that applies as much to health as to disease. On this basis, four types of underdiagnosis of health are identified, three of which are inherently related to overdiagnosis of disease. Unlike overdiagnosis, which is primarily detectable at the population level, underdiagnosis of health can often be identified at the level of the individual clinical encounter. Given the asymmetry of aversion-where omissions are often judged more harshly than commissions-there may be a stronger moral appeal to avoid underdiagnosis of health than to avoid overdiagnosis of disease. However, there are conceptual and practical challenges associated with underdiagnosis of health. CONCLUSION: While acknowledging the many challenges with the concept, focusing on underdiagnosis of health may be a fruitful strategy to mitigate medical overactivity including overdiagnosis of disease.